More than 60% of older adults enter the hospital through the Emergency Department. GEDs have demonstrated their heightened relevance during the pandemic in providing age-appropriate care and strengthening future public health emergency preparedness through developing and disseminating targeted recommendations, resources, trainings, and telehealth implementation support for healthcare staff. Many changes implemented during the pandemic should continue post-COVID.
Geriatric Emergency Department, hospitalization, dementia, West Health, Gary and Mary West Senior Emergency Care Unit, UC San Diego Health
Twenty million older adults use the emergency department (ED) each year and do so more often than any other age group. Older adults account for 46% of all ED visits resulting in hospitalization and more than 10% of those visits are avoidable. More than 60% of all older adults hospitalized in the United States enter the hospital through the ED.
The traditional paradigm of emergency care was not designed to identify underlying complex healthcare and social support needs of older adults such as polypharmacy risks and medication adverse events, recurrent falls, or a lack of adequate supports in the home environment. Despite the time pressure and limitations in the ED, crucial emergency care continues to evolve for older adults by identifying underlying geriatric syndromes and social vulnerabilities to provide the best care possible in the ED, and enable safe, coordinated transitions to home or to other most appropriate settings when possible.
The American College of Emergency Physicians (ACEP)’s GED accreditation (GEDA) program recognizes more than 300 EDs that have made a commitment toward providing quality care for older adults through three tiers of accreditation. With the support of West Health, the Gary and Mary West Senior Emergency Care Unit (SECU) at UC San Diego Health was in 2018 part of the first cohort to receive the top level of Geriatric Emergency Department (GED) accreditation. The foundational GED model acknowledges the unique needs of older patients and focuses on implementing best practices in acute and post-acute care for older adults.
This includes specialized screenings, referrals, protocols, and policies for common issues faced by older adults, including those relating to mobility, cognitive impairment, and post-acute transitions of care. The SECU at UC San Diego Health also is a founding member of the Geriatric Emergency Department Collaborative (GEDC), which now includes more than 60 hospital sites and serves as a critical forum for developing and disseminating educational resources and research on GED best practices. Both the GEDA and the GEDC rely upon contributions of leading institutions and clinicians in geriatric emergency medicine, as well as support from The John A. Hartford Foundation (JAHF) and the Gary and Mary West Health Institute (WHI). GEDs have made it possible for older adults to be cared for when needed, while reducing the need for hospitalization by up to 16%.
What Became More Difficult in the ED During COVID?
The COVID-19 pandemic made caring for older adults in the SECU and in EDs across the country more challenging. The unprecedented epidemic has exacerbated older adults’ unique vulnerabilities and underscored the need for this type of specialized care in the ED. While patients of all ages are at risk for infection, older adults continue to be the most vulnerable due to their advanced age and increased co-morbidities. In addition, we have seen elders delay needed medical care out of fear of exposure to the contagion in healthcare facilities.
‘GEDs have made it possible for older adults to be cared for when needed, while reducing the need for hospitalization by up to 16%.’
When older adults did present to the ED, they faced new challenges to receiving the best care. At the SECU and at EDs across the country, COVID-related hospital visitation restrictions implemented at the start of the pandemic at times impeded optimal care for older adults. This was especially true for people living with dementia who often rely upon caregivers to convey their medical history and needs, as well as for emotional support in the ED environment. COVID protective gear could be disorienting for older adults with cognitive impairment (including dementia and delirium) and could impede communication with older adults that are hard of hearing, who may rely, at least partially, upon lip-reading.
Particularly pertinent has been overcrowding and capacity challenges hospitals have faced during the pandemic. COVID testing processes, nursing shortages, and hospital isolation protocols significantly slowed disposition and admitting processes and often led to overcrowding. This resulted in much higher ED length of stay and boarding times at many hospitals, which then can lead to heightened risk of adverse impacts including delayed care and increased agitation and/or disorientation. These conditions can increase the risk of incident delirium, which in turn may increase the likelihood of a hospital admission that otherwise may have been avoided.
What Did GEDs Do to Respond?
Fortunately, individual and institutional leaders in geriatric emergency medicine have responded in a time of crisis by leveraging and building upon existing GED infrastructure. GEDs have demonstrated their heightened relevance during the pandemic in providing age-appropriate care and strengthening future public health emergency preparedness through developing and disseminating targeted recommendations, resources, trainings, and telehealth implementation support for healthcare staff.
Changes in policy driven by GED champions recognized caregivers’ role as partners in care (not visitors) for people living with dementia, and as the learning network of GEDs shared their experience, this change in practice spread more widely. The GEDC learning network was also able to exchange solutions to lessen the potential impact of protective gear on older adults’ patient experience, such as name tags with photos and providing tablets for video conferencing with family members.
As part of the GEDC, the UC San Diego SECU and other member sites have served as a key source of information on COVID-19 testing and treatment, including providing an up-to-date “living library” of resources, multiple COVID-19 webinars for clinicians and administrators, a COVID-19 in the ED implementation toolkit, as well as serving as the home of the Journal of Geriatric Emergency Medicine, which has released multiple research and clinical practice articles on managing COVID-19 in the older adult ED population. Accordingly, GEDC has become the hub to which EDs turn for COVID-19 information, and its educational outreach has included 18 webinars in the past 26 months, with an average attendance of 120 participants and more than 500 on-demand views.
The Geriatric Emergency Department Collaborative has become the hub to which EDs turn for COVID-19 information.
ACEP also has been at the forefront in providing COVID-19 resources to its members, including treatment and management information, learning opportunities, GEDA accreditation updates related to COVID-19, and policy updates.
In response to the pandemic’s perilous effect on older adult populations, COVID-19 resources were developed and widely distributed, such as “COVID-19 Protocols and Policies” and a webinar “COVID-19 in Older Adults, Key Points for EDs.” ACEP also has helped formalize the approach to using telehealth in the geriatric ED as it allows older adults needing care to avoid the dangers of virus transmission in the ED.
And, hospitals, health systems, and clinicians have been the key to identifying and implementing best practices for caring for older adults in the ED during the pandemic. While there are many examples of GEDs making a positive impact, one such case is within and across the University of California (UC) system. Throughout the pandemic, a UC-wide GED network has hosted monthly discussions including the exchange and dissemination of key information and resources to clinical team leads at each of the six UC health system sites across the state.
What Changes Should We Keep and Scale to Transform ED Care for Older Adults?
COVID-19 exposed underlying weaknesses in our healthcare system, yet it also presented opportunities to improve upon existing policies and practices. Now, for the benefit of our nation’s older adults, we must ensure that the lessons learned and improvements made by the geriatric emergency medicine community during COVID continue and expand when the crisis ends.
Changes we hope to maintain after the crisis include improved visitation policies that recognize caregivers as essential partners in care for persons living with dementia, an increased emphasis on communication aids in the ED, and enhanced telehealth access and reimbursement to keep older adults out of the ED when possible. We also will continue to look for alternatives to hospitalization for older adults, to do what is best and what matters most to patients (avoiding admissions also is financially positive for many healthcare systems because it fosters a better case mix index and reduces overcrowding, especially as hospital beds and nurses remain scarce.)
The GED movement is well-positioned to sustain and scale innovations in care for older adults in the ED, throughout the COVID pandemic and beyond. With support from WHI and JAHF, there are a number of far-reaching plans in place to spread best practices in geriatric emergency care, from programs to accelerate health system adoption (including across the Veterans’ Health Administration, which is working toward having 70 of its EDs apply for GED accreditation by the end of 2022) to statewide initiatives in California (supported by WHI) and New York (supported by JAHF).
In California, the State’s Master Plan for Aging has set a goal of expanding GED care in hospitals and health systems with specialized training for multidisciplinary staff and teams. The West Health Institute and UC San Diego are convening a coalition of public and private stakeholders to position California as the first state in the nation where every older adult has access to a GED. To achieve this, we’ve activated a statewide public-private Senior Emergency Care Network (SECN) to serve as the backbone for spreading GEDs across California and advancing the best possible care for its older adults. The SECN initiative aims to triple the number of GEDs in California within three years by supporting an additional 50 EDs to gain GED accreditation. Once achieved, more than 20% of California’s EDs would provide accredited GED services.
COVID has undoubtedly taken a huge toll, especially on older adults. It also has posed enormous challenges for clinicians, hospitals, and the U.S. healthcare system. Yet the remarkable response to these challenges has uncovered opportunities and catalyzed action to sustain realized improvements for patient care, for older adults in the ED, and beyond.
Kevin Biese, MD, MAT, is an associate professor in Emergency Medicine, director of the Division of Geriatric Medicine, and vice-chair of Academic Affairs at the University of North Carolina School of Medicine in Chapel Hill, NC. Adrienne Lesser, MS, MBA, is director, Market Development at Phreesia in Raleigh, NC.