Rosa McNamara is a consultant in emergency medicine in London, with a special interest in geriatric emergency medicine. She tweets @rosamcnamara
So we all know that the world is growing older – it is now common for emergency department (ED) clinicians to spend the majority of their day looking after frail older adults. In emergency medicine (EM) we are going through a longish period of reflection on how best to care for older adults (EM is just over 40 years old, and for 30 of those years there has been discussion about this). Interest in the needs of frail older adults has widened and many solutions have been tried in EDs worldwide, with mixed results. These include rapid response teams, liaison geriatrics, interface geriatrics and the development of seniors EDs.
There are many reasons why EDs and emergency clinicians are not meeting the needs of older adults. The physical environment is designed to maximise throughput of patients – cubicles are close together and filled with handy things you might need, patients are moved through different areas of the ED for different processes to occur – triage/rapid assessment/majors/resus. There are about 7 places you can be sent from triage, and for most people they will have 2-3 transitions of care whilst in the ED.
It is chaotic, cluttered, noisy, and busy; people are constantly moving around, the corridors and free floor space often double up as trolley bays; police come, people shout, people cry, babies scream, alarms herald the arrival of the unstable, and machines hum and buzz constantly. This is my environment and the one in which my kind thrive – however I understand why everyone apart from the species known as ‘interface geriatrician’ dodges the ED! How, you ask, is anyone meant to make a decision here? How is anyone not meant to get delirious after 4 hours of sitting here?
Patients may also get ‘inappropriately’ referred on the clinical decision units, frailty units and even to on-call teams where there is more time to make phone calls to GPs, relatives, social workers, care agencies and find the kindly neighbour who is minding the keys but doesn’t have a mobile and was out shopping all day. Time is also needed to get the key safe installed and the door fixed (having been knocked down to access an immobile patient). In the target-driven world in which I live this is almost impossible – I need to have the patient seen within 1.5 hours and a disposition decision made within 2.5 hours of arrival. That is why decisions are sometimes made in haste.
So what is the solution? The debate in geriatric EM at the moment is whether we should make all EDs “frail-friendly”, or should we develop dedicated departments for frail older adults? Before I say more about this I want you to think about paediatric EM. Paediatric EDs are a new thing – during my training I mostly worked in mixed departments where all comers were seen together. The debate on needing to separate paediatric from adults department was won (slowly) by pointing out quite simply that children had differing physical, psychological and social needs compared to adults. They required both nursing and medical expertise focused on these needs and paediatric pathology so that accurate diagnosis and safe discharge decisions were being made. Separating children both visibly and audibly from the adult department was seen to be important to reduce distress and risk to this vulnerable group. Now few of us would dream of pitching up to our local ED with a small child to be seen by a clinician with no paediatric experience in an adult department.
I suggest that all these arguments hold true for frail older adults – creating discrete departments for older adults allows us to cohort expertise, provide a more appropriate environment for caring for those that are frail, and one which is able to meet the psychological needs of older adults, particularly those with cognitive impairment.
Geriatric EDs won’t replace frailty units – which effectively function as short-stay wards in the same vein as clinical decisions units or medical assessment units. Care will move further towards the beginning of a patient’s journey and this may divert admissions and allow for better integration of services both in the community and within the hospital.
We have been thinking about this for a long time, and in that time the demand for and complexity of care delivered in the ED has increased. It is time for a bespoke solution for older adults using our emergency services, which is focused around their needs – a geriatric ED.
Image credit: Lydia via flickr
British Geriatrics Society 
I agree totally with your comments, Rosa. A particular concern for me are often unnecessary emergency admissions coming from a care home setting. Without a carer to chaperon and act as translator, the process of dealing with the patient will take longer. The patient is often confused,anxious and in need of basic care with no one to fulfill this function in A&E. I have observed this twice in one week in two different hospitals across the country.
I am studying for a degree with an interest in geriatrics. My background is in ‘live in’ palliative care and family liaison.
Agree- it’s a huge challenge for the ED team to get it right without information on health and care needs.
They need to be seen by an emergency physician with an interest in geriatrics to be able to assess acute illness and injury. We then frail elderly assessment units to optimise those who need minimal acute medical treatment but do need review. We also need geriatric trauma care and geriatricians with an interest in trauma not just orthopaedic trauma.
Completely agree- ‘traumatricians’ the subject of my next blog!
Integrating geriatrics and trauma. Check out our humble attempt from Canada:
An evaluation of a proactive geriatric trauma consultation service. Ann Surg. 2012 Dec;256(6):1098-101.
And those of our colleagues in the USA:
1. Quality of Care Delivered Before vs After a Quality-Improvement Intervention for Acute Geriatric Trauma. J Am Coll Surg. 2015 May;220(5):820-30. http://www.ncbi.nlm.nih.gov/pubmed/25840534
2. Long-term postinjury functional recovery: outcomes of geriatric consultation. JAMA Surg. 2014 Jan;149(1):83-9. http://www.ncbi.nlm.nih.gov/pubmed/24284836
Rosa, I’ve given this topic lots of thought: I think I don’t agree that the “separate” Geriatric ED is the route to go. Some American hospitals have chosen that approach — probably close to a hundred such units now exist in the US though the uniformity of their services and even their definition is very variable. And most people admit that the main driver for that change is marketing and economics (older adults are fully insured and so having differentiators that “attract” them gives your institution a market edge!)
Some arguments AGAINST a geriatric ED?
1. In most cases (except perhaps the most heavily resourced, best funded, largest urban EDs) it would be extremely difficult to staff such an ED consistently. While I’m not among them, very few EM specialists (MD or RN) are going to be interested in seeing ONLY complex older people (any more than most of us want to see ONLY children).
2. EM is by its very nature a generalist field — that’s mostly why we go into it so there would be significant concerns about de-skilling.
3. In Canada at least, most ED patients are seen in smaller community or rural EDs (all the people writing on blogs and doing academic work are in large academic EDs!): separating out the patient population (Geri, peds, Psych? Gyne? ) in those settings is really not feasible.
4. And finally I’m not ready to throw in the sponge and just say “EDs are no place for old people.” I think it is possible to make changes (to education, staffing, protocols, the physical environment) that move towards creating a SENIOR-FRIENDLY ED. This is in fact the route that most Canadian EDs have gone regarding provision of care to children (there are probably only 8-10 Peds EDs in the country — all located in heavily resourced, well funded large urban sites). Over the past 30 years though there has been a real move to ensure that Emerg clinicians develop the special skills and knowledge (and attitudes) required for care of children and that special protocols and care pathways are in place that prioritize little people. Why can’t EVERY ED do the same for old people?
All decisions are locally contextualized — and I appreciate that in the UK with a much larger and much denser population, it might be possible to create separate units even in smaller centres. However my argument contra-Geriatric EDs seems analogous to my claim that we don’t need more geriatricians (physicians who specialize in care of only older people); we need ALL doctors to be competent in care of older people.
I’m involved in several initiatives to do just that — the Hartford and West Health supported Geriatric ED Bootcamp Collaborative (in the US); the CFHI-funded Acute Care of the Elderly Initiative in Canada; the Senior-friendly ED Course we have developed.
Don Melady MD Toronto
http://geri-em.com
Don, thanks for comprehensive reply.
I think in UK&Ire time has come for GED, with core admissions and longest ED stays in older adults in most departments. I agree that the regional differences are important here.
Absolutely all departs/hospitals/healthcare facilities, along with any public buildings should be frail friendly. No argument from me there! And absolutely everyone needs to skill up across medicine to cater for the needs of an ageing population.
For GED- yes a mix of EM specialist’s but also geriatric RNs and MDs are needed. Key is to place skilled senior decision makers at the place where the patients are, and in a suitable environment for their needs. As an EP with a lot of interest in geriatric medicine I still know that there are gaps in my knowledge around many things such as rationalising meds or managing chronic disease and I am grateful to have access to a geriatrician to add their expertise.
Small ED’s and those with a smaller proportion of older adult patients may not feel it is possible/relevant to develop a seperate GED and that is fair enough.
US business model is not relevant within NHS/HSE models of care delivery.
Agreed!
I won’t get into the specific debate about the need for a geriatric emergency department. But having sat next to Dr Melady at the Canadian Geriatrics Society Dinner when despite having just been given an award for his contribution to the acute care of older people, he told the audience that geriatric medicine had little future, I have to take issue. The fact that Canada has trained too few geriatricians does not mean they don’t value add to care. The “we are all geriatricians now” and “what can you do that we can’t” is as old as the hills. Here is the thing though. It is no less valid to have a speciality based on the care of older people with frailty, multiple co-morbidities, age related disability, complex care needs, carers, co-morbid dementia etc than it is to have one based on an organ system. We all look after people with acute kidney injury, acute coronary syndrome, asthma or diabetes but that doesn’t make us nephrologists or diabetologists or cardiologists. We all see patients with co-existent depression but that doesn’t make us all psychiatrists. I speak to emergency physicians all the time, many working in units where geriatricians and specialist nurse practitioners come to the department to see frailer older patients. All value the input. There is a good evidence base behind what we do and those same emergency physicians admit that they would like to feel more confident in acute frailty medicine. Clearly we should all as the population ages develop competencies in the care of older people but that doesn’t negate the genuine value geriatricians add. And all of us have seen patients managed suboptimally or inexpertly by other disciplines. Rather than dismiss the contribution geriatric medicine can make and wish the speciality gone all together, Dr Melady could join Chris Simpson chair of the CMA in campaigning for more skilled clinicians in the care of older people
David Oliver
President, British Geriatrics Society
I agree with Don – both sets of competencies are needed (EM & CGA (which is not just geriatricians). The whole ED needs to be frail friendly – actually the whole hospital! The physical design is the easy bit, but embedding the clinical competencies and frailty attuned pathways and processes is more tricky. There are GEM competencies in the process of being published, that have been signed up to by EUGMS & EUSEM. There is a GEM course running in May http://em3.org.uk/gem/ – importantly for all staff, not just for EM docs or geriatricians.
I would agree here – I cannot see the GED taking off in the UK – we need to skill up our specialty in EM in such a way that we can initiate appropriate management of the elderly patient in an acute situation and then liaise closely with our geriatric colleagues to have an efficient and smooth transition into a pathway of care – whether that is in the CDU, ward setting or community. The fact is that ALL EDs need to understand that the elderly are becoming our bread and butter and we need to be prepared for this by having a skillset ourselves but also being able to have those boundary spanning connections with others to manage the patients appropriately. There is precious little evidence to support any approach in the ED – we really need to encourage funding of studies to help us shape the future care for these patients.
Did you just use the ‘e-word’ sue?
Interface geriatrics requires a new kind of skill set, new relationships and really wide range contacts of ‘go to’ people ‘care coordinators’.
Key is to make the role exciting attractive and fulfilling as well as requiring teams without walls.
Commissioner behaviour also needed to change to support this innovation with appropriate trust for partners to deliver patient orientated outcomes and sensible gain share leavers
The fact is this is ‘real world’ acute medical care and every department esp. ED has to be frailty attuned. I agree with David and believe geriatric medicine is perhaps the most essential specialty in modern medicine. I would argue that most acute hospitals need more/only geriatricians to run acute medicine. The main issue in the UK is workforce in emergency, acute and geriatric medicine.