Luna Ragsdale

Geriatric Emergency Department guidelines

INTRODUCTION According to the 2010 Census, more than 40 million Americans were over the age of 65, which was “more people than in any previous census.” In addition, “between 2000 and 2010, the population 65 years and over increased at a faster rate than the total U.S. population.” The census data also demonstrated that the population 85 and older is growing at a rate almost three times the general population. The subsequent increased need for health care for this burgeoning geriatric population represents an unprecedented and overwhelming challenge to the American health care system as a whole and to emergency departments (EDs) specifically. Geriatric EDs began appearing in the United States in 2008 and have become increasingly common. The ED is uniquely positioned to play a role in improving care to the geriatric population. As an ever-increasing access point for medical care, the ED sits at a crossroads between inpatient and outpatient care (Figure 1). Specifically, the ED represents 57% of hospital admissions in the United States, of which almost 70% receive a non-surgical diagnosis. The expertise which an ED staff can bring to an encounter with a geriatric patient can meaningfully impact not only a patient’s condition, but can also impact the decision to utilize relatively expensive inpatient modalities, or less expensive outpatient treatments. Emergency medicine experts recognize similar challenges around the world. Geriatric ED core principles have been described in the United Kingdom. Furthermore, as the initial site of care for both inpatient and outpatient events, the care provided in the ED has the opportunity to “set the stage” for subsequent care provided. More accurate diagnoses and improved therapeutic measures can not only expedite and improve inpatient care and outcomes, but can effectively guide the allocation of resources towards a patient population that, in general, utilizes significantly more resources per event than younger populations. Geriatric ED patients

Randomized Clinical Trial of an Emergency Department Observation Syncope Protocol Versus Routine Inpatient Admission

STUDY OBJECTIVE Older adults are frequently hospitalized from the emergency department (ED) after an episode of unexplained syncope. Current admission patterns are costly, with little evidence of benefit. We hypothesize that an ED observation syncope protocol will reduce resource use without adversely affecting patient-oriented outcomes. METHODS This randomized trial at 5 EDs compared an ED observation syncope protocol to inpatient admission for intermediate-risk adults (≥50 years) presenting with syncope or near syncope. Primary outcomes included inpatient admission rate and length of stay. Secondary outcomes included 30-day and 6-month serious outcomes after hospital discharge, index and 30-day hospital costs, 30-day quality-of-life scores, and 30-day patient satisfaction. RESULTS Study staff randomized 124 patients. Observation resulted in a lower inpatient admission rate (15% versus 92%; 95% confidence interval [CI] difference -88% to -66%) and shorter hospital length of stay (29 versus 47 hours; 95% CI difference -28 to -8). Serious outcome rates after hospital discharge were similar for observation versus admission at 30 days (3% versus 0%; 95% CI difference -1% to 8%) and 6 months (8% versus 10%; 95% CI difference -13% to 9%). Index hospital costs in the observation group were

Optimal older adult emergency care: introducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine.

629 (95% CI difference -

Overtreatment of Presumed Urinary Tract Infection in Older Women Presenting to the Emergency Department

1,376 to -

Acute Abdominal Pain in the Older Adult

56) lower than in the admission group. There were no differences in 30-day quality-of-life scores or in patient satisfaction. CONCLUSION An ED observation syncope protocol reduced the primary outcomes of admission rate and hospital length of stay. Analyses of secondary outcomes suggest reduction in index hospital costs, with no difference in safety events, quality of life, or patient satisfaction. Our findings suggest that an ED observation syncope protocol can be replicated and safely reduce resource use.

Health care utilization before and after an outpatient ED visit in older people.

In the United States and around the world, effective, efficient, and reliable strategies to provide emergency care to aging adults is challenging crowded emergency departments (EDs) and strained healthcare systems. In response, geriatric emergency medicine clinicians, educators, and researchers collaborated with the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine to develop guidelines intended to improve ED geriatric care by enhancing expertise, educational, and quality improvement expectations, equipment, policies, and protocols. These Geriatric Emergency Department Guidelines represent the first formal society‐led attempt to characterize the essential attributes of the geriatric ED and received formal approval from the boards of directors of each of the four societies in 2013 and 2014. This article is intended to introduce emergency medicine and geriatric healthcare providers to the guidelines while providing recommendations for continued refinement of these proposals through educational dissemination, formal effectiveness evaluations, cost‐effectiveness studies, and eventually institutional credentialing.

Older patients' understanding of emergency department discharge information and its relationship with adverse outcomes.

To determine how often older women presenting to an emergency department (ED) are diagnosed with a urinary tract infection (UTI) without a positive urine culture and to investigate whether collecting urine by catheterization instead of clean catch improves the accuracy of the urinalysis (UA).

Optimal older adult emergency care: Introducing multidisciplinary geriatric emergency department Guidelines from the American college of emergency physicians, American geriatrics society, emergency nurses association, and society for academic emergency medicine

Abdominal pain in older adults is a concerning symptom common to a variety of diagnoses with high morbidity and mortality. Organizing the differential into categories based on pathology (inflammatory, obstructive, vascular, or other causes) provides a framework for the history, physical, and diagnostic studies. An organized approach and treatment and considerations specific to the geriatric population are discussed.

A survey to define the minimally essential attributes of the geriatric emergency department

BACKGROUND Older adults in the United States receive a significant amount of care in the emergency department (ED), yet the associations between ED and other types of health care utilization have not been adequately studied in this population. OBJECTIVES The goals of this study were to examine the relationships between health care use before and after an ED visit among older adults. METHODS This retrospective cohort study examined health care use among 308 patients 65 years or older discharged from a university-affiliated ED. Proportional-hazards models were used to assess the relationship between pre-ED health care use (primary care physician [PCP], specialist, ED, and hospital) and risk of return ED visits. RESULTS Older ED patients in this study had visited other types of providers frequently in the previous year (median number of PCP and specialist visits, 4). Patients who used the ED on 2 or more occasions in the previous year were found to have visited their PCP more often than those without frequent ED use (median number of visits, 7.0 vs 4.0; P < .001). Despite more PCP use in this population, frequent ED use was associated with increased risk of a repeat ED visit (hazard ratio, 2.20; 95% confidence interval, 1.15-4.21), in models adjusted for demographics and health status. CONCLUSION Older adults who use the ED are also receiving significant amounts of care from other sources; simply providing additional access to care may not improve outcomes for these vulnerable individuals.