2. Becoming an Accredited Geriatric Emergency Department: How and Why
Developed with support from

3. “Overcoming the Challenges of Geriatric Acute Care" Christina Shenvi, MD, PhD, FACEP

4. Disclosures
None
Disclosures

5. If you want more on geriatric EM …
GEMcast on itunes
@gempodcast
@clshenvi

6. Today I’ll be talking about meeting the challenges of geriatric acute care, and I am at least as excited as these folks to be here to share this with you today.

7. Older Adults by the Numbers: Currently
13% of the population
15% of ED visits
35% of EMS arrivals to ED
40% of ED hospital admissions
50% of ED critical care admissions
US Census Bureau, CDC Fast Stats, Mullins et al. Acad Emerg Med :5

9. This is unprecedented in the history of the world
This is unprecedented in the history of the world! So it should surprise us not at all that we will be facing new challenges.

10. Older Adults by the Numbers: 2030
Older adults use the ED more per person than any other age group.
20% of the population
25% of ED visits
50% of EMS arrivals to ED
US Census Bureau; Wilber et al. Acad Emerg Med ; Platts-Mills et al. Prehosp Emerg Care :3

11. Older Adults by the Numbers
Adults age 65 and over are the fastest growing demographic
70 million
(20%)
40 million
(13%)
31 million
(12.6%)
Population 65 and over in millions
Older adults are the fastest growing segment of population. If we look at this population graph, and then also consider…
Year
US Census Bureau, DHHS Administration on Aging

12. Annual Per Capita Healthcare Costs by Age
The healthcare costs per age. The US is in red, and you can see that around age 55 or 60, we see an enormous increase in per capita healthcare costs. So what will we get in the coming decades as we consider both of those graphs? What’s going to happen to the US economy and the healthcare system?

13. It’s going to explode!! And in centuries to come, I hope they will not talk about the healthcare crisis and the aging population as they do now about how taxation, unemployment, slavery, and disease led to the fall of Rome.

14. The landscape, in fact, looks bleak
The landscape, in fact, looks bleak. And we could sit here and complain about it and predict doomsdays and the fall of our civilization. Or we could do something about it.

15. Goal: A Geriatric Paradigm Shift
What I hope we can achieve throughout this morning’s conversations is a paradigm shift. We need to leave the comfortable waters of how we’ve done things in the past, and find new ways to meet the challenges of caring for older adults.

16. The Challenges to Geriatric Acute Care
The numbers, the cost, the time, and the complexity. I’m going to illustrate these challenges using three examples, of falls, delirium, and polypharmacy.

17. Geriatric
Syndromes
In order to illustrate some of those challenges, I want to introduce the concept of geriatric syndromes.

18. “Multi-factorial health conditions that occur when the accumulated effects of impairments in multiple systems render an older person vulnerable to situational challenges.”
Tinetti et al. JAMA :3

19. Geriatric Syndromes Falls Frailty Delirium Dehydration
Other syndromes:
Hearing loss
Vision loss
Constipation
Aspiration
Incontinence
Cognitive impairment
Anorexia
Decubitus ulcers
Sleep disorders

20. Falls
Delirium
First let’s talk about falls

22. Mrs. Brown:
85yo F who relies on a walker or cane at baseline, with multiple chronic medical conditions, has difficulty driving, who presented after a trip and fall, with a R sided forearm fracture.
We also find out she has had several recent falls. Can we discharge her?

23. Falls Acute/chronic illness Cognitive impairment
Medications/ Polypharmacy
Decreased mobility/balance
Fall history
Sensory deficits
Alcohol use
Postural hypotension
Depression
Use of assistive devices
Environmental factors
Well, let’s think about it. There are probably many things that went into making her at risk for falls, such as…

24. The injury that we see an older patient for in the ED, is often the just the top of the iceberg. It’s the small manifestation of a much bigger underlying syndrome. We often don’t want to think about all that morass of iceberg under the water, because we think “what can we do about it?” “that’s not an ER doc’s job.”

25. Falls Optometrist Audiologist Counsellor or PCP PCP NeurologistPT
Acute/chronic illness
Cognitive impairment
Medications/ Polypharmacy
Decreased mobility/balance
Fall history
Sensory deficits
Alcohol use
Postural hypotension
Depression
Use of assistive devices
Environmental factors
NeurologistPT
PT/OT
Psychiatrist or therapist
Geri-pharmacist
PCP or Psychiatrist or Neurologist
PT Orthotics
To really address these problems we’d need a huge team, but we don’t have that in the ED.
Geriatrician
or PCP
Home Assessment

26. We typically have a doc or an APP, a nurse, and if you’re lucky, a case manager. So how can we possibly address all the patient’s needs? The answer is, we can’t. With our current systems, we can’t. So what do we need to do?

27. What could we do better?
We also find out she has had several recent falls. Can we discharge her?

28. 1. We need to build better systems
We need to start putting up the scaffolding to build better systems of care. So that we can arrange what the patient needs, such as home PT, or home aids, or discharge to an acute rehab or nursing facility, or if she’s ok after this fall, follow up in a falls clinic or with a home visit to prevent future falls. We don’t have the time in the ED to build this and take it down each shift. It needs to be in place.

29. Falls
Delirium

30. 72yo F with a history of mild cognitive decline, living independently
72yo F with a history of mild cognitive decline, living independently. She came in for urinary frequency and mild confusion (put her laundry in the fridge instead of the washer). We diagnose her with a urinary tract infection and discharge her.
Mrs Johnson:
77yo F with a history of mild cognitive decline, living independently. Presented for urinary frequency and mild confusion (put her laundry in the fridge in instead of the washer). Diagnosed with a UTI.
9/21/2019

31. Potential Outcomes
And maybe, she will go home, take her meds, follow up with her PCP and do just fine. But maybe she is a little too confused to navigate a way to get transportation to get her meds. Maybe she doesn’t follow up

32. Maybe she’s not coping as well at home as she said she was
Maybe she’s not coping as well at home as she said she was. Maybe we missed the fact that she was showing signs of delirium

33. Potential Outcomes
Maybe if we’d picked up on the delirium by using a screening tool in the ED, we might have realized that she wasn’t ok to be discharged. Or, if she’d had a system in place for a next day check or call at home, maybe it would have been caught that she wasn’t improving or hadn’t picked up her meds.

34. What could we do better?
72yo F with a history of mild cognitive decline, living independently. She came in for urinary frequency and mild confusion (put her laundry in the fridge instead of the washer). We diagnose her with a urinary tract infection and discharge her.

35. 1. We need to build better systems. 2. We need to use better tools.
We need to have systems in place that could be hospital at home or some intermediate or some sort of home visit or closer communication with the PCP. We need to build protocols for screening and identification of geriatric syndromes such as delirium or falls risk, and have ways to set up outpatient services and home services. For some things we have tools, like delirium screening, and the ISAR to screen for risk of adverse outcomes, but it isn’t implemented broadly. For other things, the tools aren’t great. We need to find ways to predict who will do well at home, and maybe we need to have systems in place to check on high risk patients after an ED visit.

36. POLYPHARMACY

37. “This small white pill is what I munch at breakfast and right after lunch. I take the pill that’s kelly green before each meal and in between. These loganberry-colored pills I take for early morning chills. I take the pill with zebra stripes to cure my early evening gripes. These orange-tinted ones, of course, I take to cure my charley horse.
I take three blues at half past eight to slow my exhalation rate. On alternate nights at nine p.m. I swallow pinkies. Four of them. The reds, which make my eyebrows strong, I eat like popcorn all day long. The speckled browns are what I keep beside my bed to help me sleep This long flat one is what I take if I should die before I wake.”
Dr. Seuss, You’re only old once

38. Mr. Smith:
84yo M with unknown PMH, on unknown meds, who was seen 3 days prior at another ED and started on a new med. He presents with syncope and hypotension.
We have no pharmacist to help find out that information. No case manager to help locate family, and no way to access his records from his visit 3 days ago when he was started on new meds.

39. Polypharmacy Falls Delirium/Confusion Hypotension Syncope
Drug/drug interactions
We know that polypharmacy is a huge contributor to falls and also to adverse drug reactions, hypotension, and sometimes delirium, and yet most places don’t have routine pharmacy med recs or have guidelines for deprescribing. In addition, we don’t have the processes to allow communication and sharing of medical records.
Freeland et al. Ann Pharmacother :9; Zia et al. Postgrad Med :3;
De Jong et al. Ther Adv Drug Saf :4; Woolcott et al. JAMA Int Med :21 Freeland et al. Ann Pharmacother 2012; 46(9)

40. What could we do better?

41. 1. We need to build better systems. 2. We need to use better tools.
3. We need to work together.

42. We Need to Work Together
ED MD
Inpt MD & PCP
Geri RN
Home services and care
Rehab, SNF, ALF
Patient
Family
ED Pharm
From patient to physician, from ED doc to pcp, from one hospital system to another, from one state to another, to share medical records and images
Social Work

43. The Challenges to Geriatric Acute Care
In summary, these are some of the challenges that we can foresee in the future. The sheer number of geriatric patients that will be coming into the ED, the cost of care, the time it takes to adequately meet all the needs of these patients, and the systems that we need in place to really provide the care that patients need, to avoid unnecessary admission.

44. 1. We need to build better systems.
2. We need to use better tools.
3. We need to work together.
By building better systems of care within our own EDs, with protocols for identifying high risk patients, providing them the care they need in the ED and at home or transferring to an appropriate facility in a timely manner, we can provide better, sustainable care for our geriatric patients. This requires more than the work of individual physicians or nurses. It requires us all to work together. It requires the support of our professional organizations. It requires lobbying, it requires good studies and data.

45. Changing the natural course of the future requires more than the work of individual physicians or nurses. It requires us all to work together. It requires the support of our professional organizations. It requires lobbying, it requires good studies and data to base our interventions on. It requires funding reform. It requires inter-disciplinary and inter-professional teamwork, it requires champions. It requires all of us.

46. Goal: A Geriatric Paradigm Shift
This is not how we’ve done things in the past!

47. Looking back at this bleak landscape
Looking back at this bleak landscape. One option would be to just bury our heads in the gravel and complain that we can’t do things differently than how we’ve done them in the past. Or, if we start working together, making our case to those in hospital systems leadership, building the systems we need, using the best tools we can….

48. Maybe, we can build something amazing.

49. Thank You! Christina Shenvi cshenvi@med.unc.edu @clshenvi @gempodcast

50. Image Credits

51. “ACEP Addresses the Need for Geriatric Emergency Medicine” Kevin Klauer, DO, EJD, FACEP 

52. “Critical Need for Emergency Department Innovations to Improve Care for Seniors” Kevin Biese, MD, MAT, FACEP 

53. Seniors make up 43% of all hospitalizations originating in the ED
EDs sit at the crossroads of multiple healthcare settings serving both emergent and non-emergent healthcare needs
Seniors make up 43% of all hospitalizations originating in the ED
The ED is often viewed as a medical and social “safety net”
Making sure the ED is equipped to address senior-specific medical and social needs is vitally important
EDs sit at the crossroads of multiple healthcare settings serving both emergent and non-emergent healthcare needs
Seniors have specific medical and social needs unlike other segments of the population, and the ED addresses both (medical services, and care transitions)
The ED is often viewed as a medical and social “safety net” so making sure the ED is equipped to address senior-needs is vitally important

54. Why Geriatrics & the ED? Hospital admissions from ED (%)
Total ED visits (millions)
What is the red line?

55. Four Critical Components of a Geriatric-Appropriate ED
Structure
Processes
Education
Connection with community
EDs are also often referred to as the “front porch” of healthcare, where treatment is provided with attention to what happens after the patient leaves the ED. There are 4 critical components of Geriatric Appropriate ED:
Structure (quieter, room for family, softer lights)
Processes (screening, case management, GEM nurses)
Education (nursing and physician geriatric education)
Connection with community (PCP referral, home health, Meals on Wheels)
Geriatric ED Guidelines 2014

56. Level 3 is designed to be within reach of every hospital
This work has led ACEP to create a program to recognize qualifying EDs as accredited Geriatric emergency departments. Developed by leaders in emergency medicine, ACEP’s GEDA will ensure that older patients with unique needs receive well-coordinated, quality care at the appropriate level at every ED encounter.
The three levels of accreditation have increasing requirements. Level 3 is designed to be within reach of every hospital, and Levels 2 and 1 are designed to reflect an increasing commitment to senior-specific care in the ED. Hospitals are encouraged to start at the level most appropriate for their institution given current resources and strive to reach higher levels of accreditation over time.
Levels 1 and 2 are designed to reflect an increasing commitment to senior-specific care in the Emergency Department.
Level 3 is designed to be within reach of every hospital

57. With 10,000 people turning 65 every day and concern growing about our nation’s unsustainable healthcare cost trajectory, West Health and The John A. Hartford Foundation are taking the lead and working together to improve geriatric emergency care.
Both organizations are dedicated to successful aging and improving the care of older adults, and they are supporting ACEP’s creation of a new geriatric emergency department accreditation program.

58. Improve patient outcomes and satisfaction Reduce medical complications
GOALS:
Improve patient outcomes and satisfaction
Reduce medical complications
Provide senior-focused emergency care to prevent avoidable hospitalizations
The ultimate goal is to have 200 hospitals become GED-accredited by the end of 2019.

59. GED: ROI Analysis Hospital Benefits:
Reduce ED bounce backs and hospital readmissions
Reduce readmission penalties
Reduce penalties for preventable errors
Increase CMI
Increase market share
Differential reimbursement
Increase satisfaction scores
Added Cost/
Investment
Hospital Costs:
Modifications to space
Staffing
Training
Equipment, supplies
Avoided Costs
Added Revenue/
Gain
Benefit to Patients and Caregivers:
Provide a trusted & reliable
connection to community-
based resources
Improve patient outcomes
Reduce iatrogenic complications
Qualitative Benefits

60. Level III Level II Level I Three Levels
Gold standard
EDs with policies, protocols, procedures, and staffing necessary to deliver and measure outcomes for geriatric patients
Obtainable by all US Emergency Departments
Modeled our “leveling” after Trauma centers since they are well-recognized in EM. For Level III we envisioned rural safety net hospital in which one provider (who is often not a physician) staffs the ED and hospital with zero access to advanced imaging or labs, let alone a geriatrician. Targeted Darrell Carter from the ACEP Rural Section to provide this perspective.
* Envision credentialing every 3 years

61. Level III Good geriatric ED care
At least one MD and one RN with evidence of geriatric-focused (champions)
Evidence of geriatric focused care initiative
Mobility Aids
Food & drink 24/7

62. Level II Center of excellence in geriatric ED care
Physician & nurse champions (medical/ nurse director) with focus on geriatric EM
Geriatric-focused nurse case manager 56 hours / week
Geriatric assessment team: 2 of PT, OT, SW, or Pharmacy available in ED
Hospital executive-assigned supervision of and support for geriatric ED resources
Geriatric EM education for MDs and RNs
Demonstrable adherence to at least 10 (of 26) policies
and protocols
QI process for selected policies
Tracking at least 3 of 11 outcome measures
Physical supplies and food/ drink
Also includes miscellaneous equipment and supplies that do not vary between Level II and Level I sites.

63. Level I Center of excellence in geriatric ED care
Physician & nurse champions (medical/ nurse director) with focus on geriatric EM + patient advisor
Geriatric-focused nurse case manager 56 hours / week
Geriatric assessment team: 4 of PT, OT, SW, or Pharmacy available in ED
Hospital executive-assigned supervision of and support for geriatric ED resources
Geriatric EM education for MDs and RNs
Demonstrable adherence to at least 20 (of 27) policies
and protocols
QI process for selected policies
Tracking at least 5 of 11 outcome measures
More physical supplies, space modifications, and food/ drink
Also includes miscellaneous equipment and supplies that do not vary between Level II and Level I sites.

64. So Far … GEDs Accredited Next Round (this week)
4 Level 1s
10 Level 3s
Next Round (this week)
6 Level 3s
3 level 2s
1 Level 1
108 sites proactively expressing interest and / or starting applications

65. Board of Governors
Kevin Biese, MD, MAT, FACEP Chris Carpenter, MD, FACEP Darrell Carter, MD, FACEP Tess Hogan, MD, FACEP Ula Hwang, MD, MPH, FACEP Marianna Karounos, DO, FACEP Nicole Tidwell – GEDA Program Manager Mark Rosenberg, DO, MBA, FACEP, FAAHPM - ACEP Board Liaison Sandy Schneider, MD, FACEP – Exofficio
Don Melady, MD Tony Rosen, MD Manish Shah, MD, FACEP Michael Stern, MD Jared Marx, MD (Exofficio)

66. Emergency Medicine is taking the lead in transition to sustainable & excellent value-based care models
ACEP’s goal is to improve care by getting ED providers and teams the resources they need to care for complex older adults
Emergency medicine is defining best practices for emergency departments
Leading the Way

67. Geriatric Emergency Department Collaboration
GEDC
Transform Care:
Broadly disseminate quality improvement programs to improve geriatric are in EDs nationwide
Catalyze Action:
Be an accelerator and central resource promoting best practices in GED care
Evaluate Impact:
Evaluate and study the impact of GEDs and GED interventions
Commitment to the dissemination and advancement of geriatric care within the
Emergency Department

68. GEDC Sites Aurora Healthcare System - WI Emory Grady Hospital - GA
Magee Women’s Hospital - PA
Mount Sinai Medical Center - NY
Northwestern Memorial Hospital - IL
St. Joseph’s Regional Medical Center - NJ
University of California, San Diego - CA
University of Chicago - IL
University of North Chapel Hill - NC

69. GEDC OPPORTUNITIES Geriatric Emergency Department BOOTCAMP
Geriatric Emergency Department COURSE
Web Based Learning ( coming soon )
Next GED COURSE * March 29, * Greater Chicago Area
Join the GEDC team
Improve the health, independence and safety of older adults.

70. Let’s take a quick break..
Thank you!
Let’s take a quick break..
Mention the GEDC bootcamp

71. Panel Discussion: “GED Goals and Sustainability” Moderated by Marcus Escobedo, MPA; Jon Zifferblatt, MD/MPH
Vaishal Tolia, MD, MPH, FACEP; UCSD Health System; Level 1
Christina Shenvi, MD, PhD, FACEP; University of North Carolina; Level 2
Aaron Malsch RN, MSN, GCNS-BC; Advocate Aurora Health Care; Level 3

72. Level 2 GED - UNC Hillsborough Hospital

73. Level 2 GEDA – UNC Hillsborough Hospital

74. UNC Hillsborough Hospital
82 inpatient beds
10 bed ED with additional flex/chair space
23k visits/year
12-15% admission rate
18% older adults

75. Aurora Health Care Geriatric EDs: Aurora Medical Center West Allis Aurora Medical Center Sheboygan Aurora St. Luke’s South Shore Aurora Medical Center Oshkosh Aurora Sinai Medical Center

76. 5 ED Demographics 2017

77. “How to Apply for GED Accreditation” Nicole Tidwell
ACEP.org/GEDA
Determine an accreditation level
Comparison overview
GEDA Criteria
Sample documents
Click “Apply Today”
ACEP Members log in with credentials
Non-members create a new account
Click the “New Application” button
Walk through physical process to applying Online.
Determine the level that suits your institution best with comparison overview. Found on website or on the back of the brochure placed in chairs today.
GEDA Criteria document goes more in depth into the criteria.
Sample application documents available for level 3.

78. Level Selection Select an accreditation level
Accept terms and conditions
Follow application prompts

79. Checklist Application fields Checklist Payment screen appears
at the end
Once application is
completed, ACEP is notified
Start the application and use the checklist to check progress
Payment screen is at the end – you can either pay via credit card or select to pay via “terms” which will get you an invoice.
That’s it!

80. Thank you! Developed with support from Contact Us
Urgent Matters is will be held in this room starting at 12:30
Lunch will be served in the back of the room
Geriatric ED Collaborative reception is tomorrow night at 5:30 in room 1B.
Developed with support from