Você está na página 1de 10

SPECIAL CONTRIBUTION

A Prole of Acute Care in an Aging America:


Snowball Sample Identication and
Characterization of United States Geriatric
Emergency Departments in 2013
Teresita M. Hogan, MD, Tolulope Oyeyemi Olade, and Christopher R. Carpenter, MD, MSc

Abstract
Background: The aging of America poses a challenge to emergency departments (EDs). Studies show
that elderly patients have poor outcomes despite increased testing, prolonged periods of observation,
and higher admission rates. In response, emergency medicine (EM) leaders have implemented strategies
for improved ED elder care, enhancing expertise, equipment, policies, and protocols. One example is the
development of geriatric EDs gaining in popularity nationwide. To the authors knowledge, this is the
rst research to systematically identify and qualitatively characterize the existence, locations, and features
of geriatric EDs across the United States.
Objectives: The primary objective was to determine the number, distribution, and characteristics of
geriatric EDs in the United States in 2013.
Methods: This was a survey with potential respondents identied via a snowball sampling of known
geriatric EDs, EM professional organizations geriatric interest groups, and a structured search of the
Internet using multiple search engines. Sites were contacted by telephone, and those conrming geriatric
EDs presence received the survey via e-mail. Category questions included date of opening, location,
volumes, stafng, physical plant changes, screening tools, policies, and protocols. Categories were
reported based on general interest to those seeking to understand components of a geriatric ED.
Results: Thirty-six hospitals conrmed geriatric ED existence and received surveys. Thirty (83%)
responded to the survey and conrmed presence or plans for geriatric EDs: 24 (80%) had existing
geriatric EDs, and six (20%) were planning to open geriatric EDs by 2014. The majority of geriatric EDs
are located in the Midwest (46%) and Northeast (30%) regions of the United States. Eighty percent serve
from 5,000 to 20,000 elder patients annually. Seventy percent of geriatric EDs are attached to the main
ED, and 66% have from one to 10 geriatric beds. Physical plant changes include modications to beds
(96%), lighting (90%), ooring (83%), visual aids (73%), and sound level (70%). Seventy-seven percent
have staff overlapping with the nongeriatric portion of their ED, and 80% require geriatric staff
didactics. Sixty-seven percent of geriatric EDs report discharge planning for geriatric ED patients, and
90% of geriatric EDs had direct follow-up through patient callbacks.
Conclusions: The snowball sample identication of U.S. geriatric EDs resulted in 30 conrmed
respondents. There is signicant variation in the components constituting a geriatric ED. The United
States should consider external validation of self-identied geriatric EDs to standardize the quality and
type of care patients can expect from an institution with an identied geriatric ED.
ACADEMIC EMERGENCY MEDICINE 2014; 21:337346 2014 by the Society for Academic Emergency
Medicine

From the Section of Emergency Medicine, Department of Medicine, University of Chicago School of Medicine (TMH), Chicago, IL;
the University of Chicago (TOO), Chicago, IL; and the Division of Emergency Medicine, Washington University in St. Louis School
of Medicine (CRC), St. Louis, MO.
Received August 5, 2013; revision received September 6, 2013; accepted September 7, 2013.
Dr. Carpenter, an associate editor for this journal, had no role in the peer review or publication decision for this paper. The
authors have no relevant nancial information or potential conicts of interest to disclose.
Supervising Editor: Lowell Gerson, PhD.
Address for correspondence: Christopher R. Carpenter, MD, MS; e-mail: carpenterc@wusm.wustl.edu. Reprints are not available
from the authors.

2014 by the Society for Academic Emergency Medicine


doi: 10.1111/acem.12332

ISSN 1069-6563
PII ISSN 1069-6563583

337
337

338

urrent (and soon to be) older adults pose a signicant challenge to the specialty of emergency
medicine (EM).14 Despite a trend favoring
increased testing, prolonged periods of observation,
and higher admission rates, studies have shown worse
emergency department (ED) outcomes in this population.57 In response to the geriatric demographic imperative, leaders from the Society for Academic Emergency
Medicine (SAEM) and the American College of Emergency Physicians (ACEP) recommend modifying the
model of emergency health care delivery to better care
for older adults.1,810 Strategies for improved ED elder
care range from the education and attitude change of
emergency providers to the redesign of ED physical
plants and departmental operational changes.1116
One recent and evolving response to the aging demographic imperative is the development of geriatric EDs.
The geriatric ED theoretically provides selected
improvements in patient care through specialized services and environmental enhancements. The rationale in
support of geriatric EDs includes inadequate EM graduate medical education in essential geriatric principles,17
as well as insufcient recognition of geriatric syndromes such as dementia and delirium.1822 In addition,
over the next two decades, the U.S. health care system
will expend a signicant and increasing proportion of
medical capital on aging adults, so developing scally
responsible alternatives to the status quo will become
increasingly urgent.23,24
The impetus to develop geriatric EDs varies.25
Although little empiric evidence exists, some reasons
include:
1. Patient benets such as establishment of more accurate diagnoses, improved therapies and health outcomes, better customer service, best practice
protocols, improved safety, and enhanced satisfaction.26
2. Hospital benets such as marketing to attract higher
reimbursement populations; growing a referral base
for higher reimbursing hospital-based programs
such as cardiac, neurologic, and orthopedic care;
physical therapy services; otolaryngology; and falls
centers.27 The onus to prevent never events or iatrogenic complications such as urinary tract infection
and decubitus ulcers begins in geriatric EDs or those
caring for geriatric adults in emergency situations.28
Additional benets could include optimization of
admission rates and length of stay and decreased
readmissions.29 More effective collaboration with
nursing homes, skilled nursing facilities, emergency
medical services, home services, and community
resources are goals of geriatric EDs.30 The expectation from cooperation of these institutions is for
improved transitions of care, health care maintenance, injury prevention, and improved patient satisfaction.31
3. Staff benets including effective and efcient practices of care; increased satisfaction; focused education to enhance competence and clinical skills; and
provision of resources such as equipment, tools, and
effective protocols and policies to facilitate the work
process.27

Hogan et al. ACUTE CARE IN AN AGING AMERICA

Although there are many reasons for a hospital to


establish a geriatric ED, no established criteria yet exist
to dene a geriatric ED. To date, each hospital with a
geriatric ED self-designates what denes its geriatric
ED. Other terms connoting enhanced service to older
adults, including senior ED, geriatric-friendly, and
elder ED, are all undened and not quantied. Current geriatric EDs range from simple marketing tools
with little substance, to areas containing only isolated
physical plant changes, to departments where unique
personnel with geriatric training offer specialized
services.
Thus far, scant published research exists to differentiate ED geriatric service provisions from general ED
operations.32,33 Although experts hypothesize about the
essential components of a high-quality geriatric ED,34,35
we provide early research to systematically identify and
qualitatively characterize the existence, locations, and
features of geriatric EDs across the United States. These
descriptive details will be essential in understanding the
variety of services offered and evaluation methods. Our
primary objective was to determine the number, distribution, and characteristics of geriatric EDs.
METHODS
Study Design and Population
This study was approved by the University of Chicago
Institutional Review Board, with exemption from
informed consent requirements. As depicted in Figure 1,
from October 2012 through May 2013, the search for
existing geriatric EDs was initiated by using a snowball
sample36 of seven known geriatric EDs. Snowball sampling is a nonprobability sampling technique in which
identied study subjects recruit or identify other possible
subjects from among their acquaintances or from potential subjects known by any means. It is a particularly useful sampling method for difcult to identify subjects and
hidden populations such as drug dealers or illegal aliens.
For our objectives, geriatric researchers and clinicians
tend to know other geriatric researchers and clinicians,
so snowball sampling serves to identify our subject population more completely. We coupled snowball sampling
with Google, Bing, and PubMed Internet searches for the
terms senior, geriatric, elder, and older adult linked with
the terms emergency department or emergency services.
E-mail snowball queries were sent to 17 institutions or
individuals (where identied) generated by these initial
identication strategies. This sample generated 22 possible sites. Multiple sample respondents named the entire
membership of the SAEM Academy of Geriatric EM
(n = 80; http://community.saem.org/saem/communities/
viewcommunities/groupdetails?CommunityKey=0a948
e78-7b61-474f-8f8a-45338fbc5e19) and the ACEP Geriatric EM Section (n = 140; http://www.acep.org/Content.
aspx?id=25112), as likely sources that could identify
potential geriatric EDs. Snowball identication prompted
queries of the memberships of these two organizations
via group listserves. Additionally, an in-person group
query occurred during the 2012 ACEP Scientic Assembly Geriatric Section meeting. Through the snowball
mechanism, the list of potential geriatric EDs grew to 46

ACADEMIC EMERGENCY MEDICINE March 2014, Vol. 21, No. 3 www.aemj.org

339

Figure 1. Snowball sampling and survey distribution. ACEP = American College of Emergency Physicians; GED = geriatric ED;
SAEM = Society for Academic Emergency Medicine.

hospitals. We contacted these sites or individuals by telephone to conrm geriatric ED existence and to identify at
each a correspondent knowledgeable in the specics of
that geriatric EDs operations. Four hospitals stated that
they did not operate geriatric EDs and were removed
from the sample. No ED or administrative personnel for
geriatric ED conrmation or sampling could be identied
in six hospitals.
Survey Content and Administration
The methodology of survey-based research has been
described recently.37 When possible, previously validated
survey instruments are preferable,38 but for our objectives, no such instrument exists. Therefore, our survey
instrument was developed by a detailed review of existing research focused on ED interventions to improve
geriatric adult emergency care,5,6,13,15,20,25,26,32,34,35,3946
as well as discussions with a multidisciplinary collaboration of representatives from SAEM, ACEP, the American
Geriatrics Society, and the Emergency Nurses Association. This collaboration continues to develop geriatric ED
infrastructure, personnel, protocol, and educational

guidelines. The members of this collaborative workgroup


helped to generate domains and questions for the survey.
The University of Chicago Center for Research Informatics
Bioinformatics
Core
(http://cri.uchicago.edu/?
page_id=1185) assisted to assess survey ease of use and
comprehensibility, as well as with the qualitative analysis
of the survey.
Thirty-six hospitals conrmed geriatric EDs, and each
identied one correspondent in the geriatric ED leadership. Each correspondent received a Research Electronic
Data Capture (REDCap, http://www.project-redcap.org/)
survey via e-mail. Respondents could win a geriatric EM
textbook as remuneration for survey response. The survey contained a snowball sample question requesting
identication of other geriatric EDs known to that individual. No additional geriatric EDs were identied
through the survey. Reminder e-mails were sent weekly
for 3 weeks to those who failed to respond. A research
assistant contacted nonrespondents via telephone.
Twenty institutions responded to the survey within the
3 weeks. The 16 that did not respond were contacted by
telephone, with 10 subsequently completing the survey.

340

Three did not respond, and three stated they did not
operate geriatric EDs. The entire survey is available in
Data Supplement S1 (available as supporting information
in the online version of this paper).
Data Analysis
Primary data analysis was performed using SPSS Statistics version 21 (IBM SPSS, Armonk, NY). We summarized survey respondents and nonrespondents using a
ow diagram.37,47 Frequency tables were created to
characterize responses.48 Categories were reported
based on general interest to those seeking to understand components of a geriatric ED or as most applicable to hospitals planning future geriatric EDs.
Categories include date of opening and location, geriatric patient volumes, number of general ED and geriatric
ED beds, physical plant changes, patient selection, staffing qualications and education, policies and protocols,
screening and assessment tools, linkage to community
services, and referral to clinical programs or services.
RESULTS
We surveyed 36 hospitals as detailed in Figure 1. Thirty
hospitals responded and conrmed geriatric ED existence. Respondents consisted of 43% physicians, 50%

Figure 2. Geriatric ED (GED) locations across the United States.

Hogan et al. ACUTE CARE IN AN AGING AMERICA

nurses, and 7% administrators. Three other sites did


not have geriatric EDs, and we were unable to establish
contact in another three. The response rate was thus
83%. Of the 30 respondents conrming presence of or
plans for a geriatric ED, 24 had existing geriatric EDs,
and six were planning to open geriatric EDs. The list of
30 respondents conrming geriatric EDs is attached as
Data Supplement S2 (available as supporting information in the online version of this paper).
The rst two geriatric EDs opened in 2008, two
opened in 2009, ve in 2010, 10 in 2011, seven in 2012,
and three in 2013. At the completion of this survey, one
identied institution planned to open a geriatric ED in
2014. The geographic locales of existing geriatric EDs
are displayed in Figure 2.
Seventy-seven percent of geriatric EDs are attached
to the main ED, some with contiguous or multipurpose
beds. Sixty-six percent have one to 10 geriatric beds
and 24% have 11 to 20 geriatric beds, while only 10%
have more than 20 geriatric beds. The total numbers of
beds in the general EDs among geriatric ED responders
are: 30% with 10 to 20 general beds, 27% with 21 to 40
general beds, and 43% with over 40 general ED beds.
The annual volume of 80% of the surveyed geriatric
EDs is 5,000 to 20,000 patients, while 10% have annual
volumes of less than 5,000 patients and the remaining

ACADEMIC EMERGENCY MEDICINE March 2014, Vol. 21, No. 3 www.aemj.org

10% have annual volumes of greater than 20,000


patients.
As described in Table 1, physical plant changes are
common among the geriatric EDs: all but one reported
changes to their beds or mattresses, while 90%
reported making modications to lighting. Respondents
also reported enhancements for corridor safety, ooring, handrails, and sound levels, as well as use of hearing and visual aids.
The majority of geriatric EDs select an age cutoff of
65 years and older for placement in the geriatric ED. In
addition to age, 60% of geriatric EDs use the Emergency Severity Index (ESI) score49 for appropriate geriatric ED placement. Most send patients with ESI Level 1
to the main ED for evaluation and stabilization, and
40% use the discretion of the triage nurse prior to
placement of patients in the geriatric ED. Seventeen
percent use geriatric-specic screening in the assignment of patients to the geriatric ED.
Seventy-seven percent of geriatric EDs have staff that
overlap with the main ED. Eighty percent report that
there are special qualications and/or educational
requirements for geriatric ED staff. Many provide geriatric ED staff with special training, such as didactics
for physicians and the Geriatric Nurse Education
(GENE) training course from the Emergency Nurses
Association50 for nursing staff. Nursing staff and
advanced practice registered nurses (APRNs) are most
likely to be uniquely assigned to the geriatric ED
with no general ED responsibilities. Those sites with
specialized geriatric ED personnel most commonly use
APRNs, geriatric nurse liaisons, case managers, and
palliative care consultants. Physician stafng assignments to the geriatric ED are listed in Table 2. In addition to provision and education of staff, it is important
to note that geriatric ED personnel may selectively
spend time on geriatric-specic tasks such as screening
and assessment, transitions of care, and medication
management.
Most geriatric EDs (87%) reported screening for at
least one of four categories of geriatric syndromes. The
most commonly used screening tools in geriatric EDs
are cognitive (77%) and functional status (73%) screens,
followed by high-risk screening (63%) and medication
management (60%). The most frequently used cognitive

Table 1
Physical Plant Changes

Change
Beds/mattresses
Lighting
Flooring skid/shine
Visual aids
Sound level
Corridor safety
Handrails
Hearing aids
Recliners
Nourishment
Other

Percentage of Geriatric
EDs Making Change
97
90
83
73
70
60
60
60
53
43
47

341

Table 2
Number of GED Physician Staff
All physicians cover both GEDandgeneralED
patients
Departments with ED physician assigned to
cover only the GED
One
1.5
l-2 dependingontimeof day
1-3 dependingontime of day
2
4
No report

6.5%

36.7%
3.3%
3.3%
3.3%
20%
6.6%
20.3%

assessment tools were Confusion Assessment Method,51


Identication of Seniors at Risk,52 mini-cog,53 minimental state examination,54 and Triage Risk Screening
Tool.55 The most commonly used screening tool for
medication management was reference to the Beers List
of inappropriate medications for elders.56 The most
common policies and protocols implemented for geriatric ED operations include falls prevention (57%),57 medication assessment (57%),58,59 delirium management
(40%),60 Foley catheter use (40%),61 and gait assessment
(37%).62,63
Ninety percent of geriatric EDs report that they solicit
direct follow-up through patient callbacks. Targeted
interventions to improve health care outcomes are common: 70% have ED staff arrange coordination of outpatient community resource services, while 63%
coordinate outpatient hospital services. Pharmacology
review is used by 73% to prevent adverse drug reactions, 67% report discharge planning for ED elders, and
60% report communication with the patients primary
care physician.
Many geriatric EDs reported that they provide
patients with extensive post-ED resources. Ninety-three
percent provide linkage to community services, such as
home aids (80%), home equipment (73%), and physical
therapy (70%). All geriatric EDs also reported postdischarge referral to at least one of the clinical service
options provided, which included skilled nursing facilities (83%), primary care providers (83%), acute rehabilitation (73%), and geriatric clinics (67%). Outcome
measures of effectiveness tracked by geriatric EDs are
as follows: 73% track hospital admissions, 70% track
patient satisfaction, 60% track hospital readmissions,
57% track repeat ED visits, and 50% track both ED
length of stay and transfer to nursing homes and skilled
nursing facilities.
When asked what resources were currently lacking to
improve the operational efciency of the geriatric ED,
major themes cited by our respondents were the
requirement for additional personnel and staff, need for
educational resources for staff, a desire for increased
administration and institutional support, and needs for
additional space. Resources needed to improve patientcentric outcomes were cited as specialized geriatric ED
personnel such as transfer coordinators and geriatric
advanced practice nurses. Additionally, respondents felt
that geriatric training of staff would improve patient
outcomes.

342

DISCUSSION
The U.S. geriatric demographic imperative,64 in conjunction with a deteriorating primary care infrastructure65 and unprecedented scal challenges, places
increasing demands on the ED. Some of the immediately measurable results of these pressures are a
constellation of elder care improvement strategies. One
such approach is the development of geriatric EDs. To
date, geriatric EDs have resulted from efforts of individual institutions or have been established by owners of
multiple hospital corporations. The preponderance of
geriatric EDs in the Midwest is attributable to one multihospital system, Trinity Health, which has developed
geriatric EDs throughout its member institutions. The
preponderance of geriatric EDs in the Northeast was
not addressed by our survey.
The constellation of geriatric EDs will vary with time,
and identication of relevant informants is complex.
Therefore, the snowball sample technique was used for
gathering data from groups that are hidden or difcult
to access. Even with this technique, identication
proved problematic. Internet searches yielded four selfidentied geriatric EDs with which conrmatory contact
could not be established. Leads from professional organizations produced three sites that denied or, upon
reection, felt that they did not operate a geriatric ED
and one with which no contact was established. It is
likely that this methodology did identify the majority of
present and planned geriatric EDs. However, any number could begin operations in the near future.
The above failures of geriatric ED identication by
EM professional organizations highlight the probability
that emergency physicians may not have a clear picture
of what constitutes a geriatric ED. Additionally, patients
searching for improved geriatric emergency care may
never identify the quality institutions they seek. Development of a clear denition of geriatric EDs is imperative to both the EM leaders shaping provision of this
care and the patients seeking care. Our results clearly
show that the denition of a geriatric ED remains
elusive. Various components and models of geriatric
EDs exist seemingly based on individual or expert opinion. No published best practices exist and no geriatric
ED offers proven outcome benets. Many geriatric EDs
share operational features, personnel, policies, and
protocols similar enough that outcome data could be
collected and analyzed. One additional long-term goal
of this research is to improve the efciency and reliability of high-quality emergency services for older adults
by dening the essential attributes of an effective geriatric ED, as well as delineating the key components likely
to improve individual targeted outcomes.
A research consortium to analyze the outcomes generated by various geriatric ED interventions may be the
most efcient manner to identify successful geriatric ED
models of care. A regional, national, or international
geriatric ED research consortium could expedite the
incorporation of key components into existing and
future geriatric EDs. The advantages of establishing a
geriatric ED research consortium include ease of
access between pertinent stakeholders to assess awareness,66 practice patterns,67 and regional variation in

Hogan et al. ACUTE CARE IN AN AGING AMERICA

outcomes.68 The ED is a unique laboratory to evaluate


underrepresented populations and acute disease phenotypes that may require different approaches to the
design and conduct of research.69
This survey is a hypothesis-generating tool. The
developers of the survey are familiar with the literature
on geriatric emergency care and attempted to identify
common strategies employed in this population. The
systematic application of these approaches through
geriatric EDs generates opportunity for more intensive
evaluation in a high-yield target group. For example,
more respondents identied existence of screening for
cognitive and functional status and medication management than identied policies and protocols to address
the same issues. A common problem in proactive
screening for problems is that positive screens may not
be linked with follow-up for issues that are identied.12
It is also interesting that time from inception of the geriatric ED was not associated with an increase in selections of any of the items. This suggests that geriatric
EDs do not increase number of interventions offered
with time. Many interesting follow-up issues arise as a
result of these survey descriptions.
Geriatric patients are a qualitatively distinct ED population with separate presentations, specic diagnostic
requirements, unique treatment strategies, particular
social and disposition needs, and outcomes divergent
from those of younger individuals.46,70,71 Geriatric ED
development is comparable to prior efforts for the care
of special populations such as pediatric EDs and Level I
trauma centers.72,73 Pediatric EM developed with the
objective to provide children with optimal emergency
care and outcomes after pediatric ED visits increased
dramatically between 1955 and 1971.72 The rst step
occurred in 1983 when ACEP hosted the Interspecialty
Conference on Childhood Emergencies, which led to
the development of an advisory committee. In 1984,
ACEP and the American Academy of Pediatrics (AAP)
formed a joint task force, and in 1989 ACEP formed a
Section of Pediatric EM. The rst journal devoted to
pediatric EM (Pediatric Emergency Care) started in
March 1985. In the late 1980s the American Board of
Emergency Medicine and the American Board of Pediatrics agreed that a subspecialty of pediatric EM should
be accessible to graduates of either EM or pediatric residencies via fellowship training. The purpose of certication in pediatric EM was to improve and ensure the
quality of patient care, teaching, and research in the
area of Pediatric Emergency Medicine.74 The number
of pediatric EM fellowship programs increased rapidly
from 24 in 1988 to 43 in 1991 and 54 in 1994, with most
based at childrens hospitals.72
The history of pediatric EM provides several lessons
for geriatric EM. First, the impetus for advancing pediatric emergency training grew out of a rapidly expanding volume of these patients, similar to the growing
awareness of a burgeoning geriatric population in the
early 21st century. Second, the process began in the
1980s with active engagement of EM and pediatric specialty societies, as well as the involvement of American
Board of Medical Specialties certifying bodies. Geriatric
EM will eventually require a similar certication
process. Third, most fellowship programs grew out of

ACADEMIC EMERGENCY MEDICINE March 2014, Vol. 21, No. 3 www.aemj.org

pediatric hospitals, emphasizing the need to develop


geriatric EDs to support specialty-training programs.
Although we recognize the similarities between developing pediatric and geriatric EM, we also note signicant differences. Pediatrics was not in the midst of a
rapid decline in the availability of pediatricians in the
1980s. The current decline of available geriatricians
places an unprecedented demand for quality geriatric
care in the hands of nongeriatrician physician providers.75 In addition, pediatric EM did not arise during an
era of increasingly constrained medical and medical
education resources, which denes our current reimbursement environment.24,76 Nonetheless, pediatric EM
provides an important historical precedent from which
to learn as geriatric EM moves forward.
The geriatric ED may be identied as a process that
occurs within the space of the general ED, as done with
stroke centers and chest pain centers. The above mechanisms for improved care of dened populations all
underwent various stages of development before ultimately seeking and gaining accreditation by external
agencies. Trauma centers are generally state-designated
with criteria varying somewhat from state to state,
although most use the American College of Surgeons
criteria and verication process. Stroke centers in most
states are certied by The Joint Commission,77 while
chest pain centers are certied by the Society of Cardiovascular Patient Care.78
Identication of centers of excellence in care was
deemed in the best interest of stroke patients by the
American Stroke Association, who in 2002 recommended the effectiveness of stroke center identication
via self-assessment, verication, certication, and
accreditation.79 Approximately a decade later, The Joint
Commission reported high levels of interest among
institutions for stroke center certication.80 In 2003,
leaders called for centers of excellence in acute myocardial infarction care.81 Systems and centers of care for
myocardial infarction patients gained momentum in
2007 with a consensus conference on systems for such
care.82 In 2012, a proposal of a national cardiovascular
emergency care system was published.83 While the outcome effect of certication per se has not been studied,
there is ample evidence to conclude that stroke center
care is associated with improved patient outcomes84,85
and that better processes of care and greater number of
eligible patients receive thrombolysis in certied centers.86 Additionally, regionalized systems accessing
trauma centers have reduced trauma morbidity and
mortality,87,88 with higher level trauma centers yielding
the best outcomes.89
The accreditation process itself signies common denitions and minimal criteria that must be met to qualify
a center as providing superior care in a given area.
Most certication criteria involve personnel with
advanced competence and continuing education and the
existence of policies, protocols, equipment, and operations that augment care to the identied population.
Currently, no criteria exist to dene appropriate population, stafng, policies, or protocols for geriatric EDs. If
the specialty can assess outcomes improvement resulting from centers of excellence in geriatric care, then the
parallels with other specialized care centers suggest that

343

external certication for excellence in geriatric emergency care may be warranted.


However, the existing failures of quality ED elder
care, coupled with the rapid demographic increase,
implies a need for expedited action.57 It took only
10 years to establish stroke center certication, which is
a targeted single disease process. It required about
20 years developing certied pediatric EDs, as this certication involves care of a population through a spectrum of diseases. In contrast, leaders in an SAEM task
force made multiple recommendations to improve ED
elder care in 1992.1 In that same 20 years, EM has failed
to develop a denitive answer to ensure improved geriatric adult outcomes.8 For a specialty that is built on
rapid response, our progress is comparably slow. We
should incorporate lessons learned from the above special populations to ensure more prompt development of
evidence supporting geriatric ED care best practices
and outcomes. We must then disseminate and apply
these solutions to enhance care for our elder population.90
If geriatric EDs are to become centers of excellence
or certied by external agencies, we must understand
the expected outcomes of these centers. Future efforts
should identify the services that are directly responsible
for optimizing specic outcomes. A list of components
enabling optimal geriatric outcomes could then be used
by external agencies to develop accredited geriatric EDs
nationwide. The aging of the American population and
their high utilization of emergency care is likely to accelerate the development of geriatric EDs. We propose
that expert consensus from individual emergency physicians, their specialty societies, and interest groups with
geriatric expertise help guide the development of existing and future geriatric EDs.
External certication may be needed to recognize and
reward centers of excellence in geriatric emergency
care, dene criteria for designation, and set minimum
standards of operation. Certication may help to motivate hospital leaders to invest in the personnel, training,
and infrastructure that is essential for geriatric EDs,
while guiding physicians seeking to establish these
centers and serve the public good.
LIMITATIONS
The limitation inherent in a snowball sample is the failure to identify one or more members in the target population.91,92 The inherent variability of this sample
population created difculty in describing features that
were common or likely to appear. The survey instrument has not been validated for content or context
validity. We can neither ensure that responses reect
reality nor conrm that respondents interpreted queries
accurately and consistently. It is possible that the majority of the population contains one or more items that
were not asked in the survey instrument, and therefore
sentinel features may have escaped description. It is
also possible that respondents did not understand individual survey questions in the same way, which could
result in dissimilar responses. Frequency tables are not
indicative of the population mean, as respondents were
able to select all the answers in a category that applied

344

to their institutions, and the exact number of observations is unknown. This description reects the state of
geriatric EDs in this country at a particular point in
time; geriatric EDs can rapidly implement new processes or eliminate others, and new geriatric EDs can
be created at any point.
CONCLUSIONS
The snowball sample identication of U.S. geriatric EDs
resulted in 30 conrmed respondents. It is likely this
technique identied the majority of existing geriatric
EDs. There is signicant variation in the components
constituting a geriatric ED. The United States should
consider external validation of self-identied geriatric
EDs to standardize the quality and type of care patients
can expect from an institution with an identied geriatric ED.
References
1. Sanders AB. Care of the elderly in emergency
departments: conclusions and recommendations.
Ann Emerg Med 1992;21:8304.
2. Roberts DC, McKay MP, Shaffer A. Increasing rates
of emergency department visits for elderly patients
in the United States, 1993 to 2003. Ann Emerg Med
2008;51:76974.
3. Pines JM, Mullins PM, Cooper JK, Feng LB, Roth
KE. National trends in emergency department use,
care patterns, and quality of care of older adults in
the United States. J Am Geriatr Soc 2013;61:1217.
4. Gruneir A, Silver MJ, Rochon PA. Emergency
department use by older adults: a literature review
on trends, appropriateness, and consequences of
unmet health care needs. Med Care Res Rev
2011;68:13155.
5. Schnitker L, Martin-Khan M, Beattie E, Gray L. Negative health outcomes and adverse events in older
people attending emergency departments: a systematic review. Australasian Emerg Nurs J 2011;14:141
62.
6. Aminzadeh F, Dalziel WB. Older adults in the emergency department: a systematic review of patterns
of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med 2002;39:2387.
7. Hastings SN, Barrett A, Weinberger M, et al. Older
patients understanding of emergency department
discharge information and its relationship with
adverse outcomes. J Patient Saf 2011;7:1925.
8. Wilber ST, Gerson LW, Terrell KM, et al. Geriatric
emergency medicine and the 2006 Institute of Medicine reports from the Committee on the Future of
Emergency Care in the U.S. Health System. Acad
Emerg Med 2006;13:134551.
9. Fitzgerald RT. White Paper: The Future of Geriatric
Care in Our Nations Emergency Departments:
Impact and Implications. Dallas TX: American College of Emergency Physicians, Oct 27, 2008.
10. Adams JG, Gerson LW. A new model for emergency care of geriatric patients. Acad Emerg Med
2003;10:2714.

Hogan et al. ACUTE CARE IN AN AGING AMERICA

11. Peterson LK, Fairbanks RJ, Hettinger AZ, Shah


MN. Emergency medical service attitudes toward
geriatric prehospital care and continuing medical
education in geriatrics. J Am Geriatr Soc 2009;57:
5305.
12. Gerson LW, Rousseau EW, Hogan TM, Bernstein E,
Kalbeisch N. Multicenter study of case nding in
elderly emergency department patients. Acad
Emerg Med 1995;2:72934.
13. Hwang U, Morrison RS. The geriatric emergency
department. J Am Geriatr Soc 2007;55:18736.
14. Banarjee J, Conroy S, Cooke MW. Quality care for
older people with urgent and emergency care
needs. Emerg Med J 2013;30:699700.
15. Schumacher JG. Emergency medicine and older
adults: continuing challenges and opportunities. Am
J Emerg Med 2005;23:55660.
16. Salvi F, Morichi V, Grilli A, Giorgi R, De Tommaso
G, Dess-Fulgheri P. The elderly in the emergency
department: a critical review of problems and solutions. Intern Emerg J 2007;2:292301.
17. Hogan TM, Losman ED, Carpenter CR, et al. Development of geriatric competencies for emergency
medicine residents using an expert consensus process. Acad Emerg Med 2010;17:31624.
18. Hustey FM, Meldon SW. The prevalence and documentation of impaired mental status in elderly
emergency department patients. Ann Emerg Med
2002;39:24853.
19. Han JH, Zimmerman EE, Cutler N, et al. Delirium in
older emergency department patients: recognition,
risk factors, and psychomotor subtypes. Acad
Emerg Med 2009;16:193200.
20. Carpenter CR, Griffey RT, Stark S, Coopersmith
CM, Gage BF. Physician and nurse acceptance of
geriatric technicians to screen for geriatric syndromes in the emergency department. West J
Emerg Med 2011;12:48995.
21. Sinha SK, Bessman ES, Flomenbaum N, Leff B. A
systematic review and qualitative analysis to inform
the development of a new emergency departmentbased geriatric case management model. Ann
Emerg Med 2011;57:67282.
22. Clevenger CK, Chu TA, Yang Z, Hepburn KW. Clinical care of persons with dementia in the emergency
department: a review of the literature and agenda
for research. J Am Geriatr Soc 2012;60:17428.
23. Cutler DM, Rosen AB, Vijan S. The value of medical
spending in the United States, 1960-2000. N Engl J
Med 2006;355:9207.
24. Chernew M, Goldman D, Axeen S. How much savings can we wring from Medicare? N Engl J Med
2011;365:e29.
25. Amini R. Particular emergency department for
seniors. Emerg Med 2012;2:e110.
26. Ryan D, Liu B, Awad M, Wong K. Improving older
patients experience in the emergency room: the
senior-friendly emergency room. Aging Health
2011;7:9019.
27. Penoza S, Pidgeon E, Rosenberg M, Thomas W.
Meet the needs of aging patients with a seniorfriendly ED. Emerg Dep Manag 2011;23:868.

ACADEMIC EMERGENCY MEDICINE March 2014, Vol. 21, No. 3 www.aemj.org

28. Mattie AS, Webster BL. Centers for Medicare and


Medicaid Services never events: an analysis and
recommendations to hospitals. Health Care Manag
2008;27:33849.
29. Hastings SN, Hein MT. A systematic review of
interventions to improve outcomes for elders discharged from the emergency department. Acad
Emerg Med 2005;12:97886.
30. Terrell KM, Hustey FM, Hwang U, Gerson LW,
Wenger NS. Quality indicators for geriatric emergency care. Acad Emerg Med 2009;16:4419.
31. Kessler C, Williams MC, Moustoukas JN, Pappas C.
Transitions of care for the geriatric patient in the
emergency department. Clin Geriatr Med 2013;
29:4969.
32. McCusker J, Verdon J, Vadeboncoeur A, et al. The
elder-friendly emergency department assessment
tool: development of a quality assessment tool for
emergency department-based geriatric care. J Am
Geriatr Soc 2012;60:15349.
33. Platts-Mills TF, Travers D, Biese K, et al. Accuracy
of the Emergency Severity Index triage instrument
for identifying elder emergency department patients
receiving an immediate life-saving intervention.
Acad Emerg Med 2010;17:23843.
34. Samaras N, Chevalley T, Samaras D, Gold G. Older
patients in the emergency department: a review.
Ann Emerg Med 2010;56:2619.
35. Carpenter CR, Platts-Mills TF. Evolving prehospital,
emergency department, and inpatient management models for geriatric emergencies. Clin Geriatr
Med 2013;29:3147.
36. Goodman LA. Snowball sampling. Ann Math. Stat
1961;32:14870.
37. Mello MJ, Merchant RC, Clark MA. Surveying
emergency medicine. Acad Emerg Med 2013;
20:40912.
38. Boynton PM, Greenhalgh T. Selecting, designing,
and
developing
your
questionnaire.
BMJ
2004;328:13125.
39. Baraff LJ, Bernstein E, Bradley K, et al. Perceptions
of emergency care by the elderly: results of multicenter focus group interviews. Ann Emerg Med
1992;21:8148.
40. Brookoff D, Minniti-Hill M. Emergency departmentbased home care. Ann Emerg Med 1994;23:11016.
41. Gold S, Bergman H. A geriatric consultation team
in the emergency department. J Am Geriatr Soc
1997;45:7647.
42. Sinoff G, Clareld AM, Bergman H, Beaudet M. A
two-year follow-up of geriatric consults in the emergency department. J Am Geriatr Soc 1998;46:716
20.
43. McCusker J, Dendukuri N, Tousignant P, Verdon J,
De Courval LP, Belzile E. Rapid two-stage emergency department intervention for seniors: impact
on continuity of care. Acad Emerg Med
2003;10:23343.
44. Foo CL, Siu VW, Tan TL, Ding YY, Seow E. Geriatric assessment and intervention in an emergency
department observation unit reduced re-attendance
and hospitalisation rates. Australas J Ageing
2012;31:406.

345

45. Yuen TM, Lee LL, Or IL, et al. Geriatric consultation


service in emergency department: how does it
work? Emerg Med J 2012;30:1805.
46. Grey L, Peel N, Costa A, et al. Proles of older
patients in the emergency department: ndings
from the interRAI Multinational Emergency Department study. Ann Emerg Med 2013;62:46774.
47. Kelley K, Clark B, Brown V, Sitzia J. Good practice
in the conduct and reporting of survey research. Int
J Qual Health Care 2003;15:2616.
48. Boynton PM. Administering, analysing, and reporting your questionnaire. BMJ 2004;328:13725.
49. Agency for Healthcare Research and Quality. Emergency Severity Index (ESI) Implementation Handbook, 2012 Edition. Available at: http://www.ahrq.
gov/professionals/systems/hospital/esi/esi2.html.
Accessed Dec 18, 2013.
sy PM, Prohaska TR. The Geriatric Emergency
50. De
Nursing Education (GENE) course: an evaluation. J
Emerg Nurs 2008;34:396402.
51. Inouye SK, van Dyck CH, Alessi CA, Balkin S,
Siegal AP, Horwitz RI. Clarifying confusion: the
confusion assessment method. A new method for
detection of delirium. Ann Intern Med 1990;113:
9418.
52. McCusker J, Bellavance F, Cardin S, Trepanier S,
Verdon J, Ardman O. Detection of older people at
increased risk of adverse health outcomes after an
emergency visit: the ISAR screening tool. J Am
Geriatr Soc 1999;47:122937.
53. Borson S, Scanlan JM, Chen P, Ganguli M. The
Mini-Cog as a screen for dementia: validation in a
population-based sample. J Am Geriatr Soc
2003;51:14514.
54. Folstein MF, Folstein SE, McHugh PR. Mini-Mental
State: a practical method for grading the cognitive
state of patients for the clinician. J Psychiatr Res
1975;12:18998.
55. Meldon SW, Mion LC, Palmer RM, et al. A brief
risk-stratication tool to predict repeat emergency
department visits and hospitalizations in older
patients discharged from the emergency department. Acad Emerg Med 2003;10:22432.
56. American Geriatrics Society. 2012 Beers Criteria
Update Expert Panel. American Geriatrics Society
updated Beers Criteria for potentially inappropriate
medication use in older adults. J Am Geriatr Soc
2012;60:61631.
57. Carpenter CR. Preventing falls in community-dwelling older adults. Ann Emerg Med 2010;55:2968.
58. Budnitz DS, Shehab N, Kegler SR, Richards CL.
Medication use leading to emergency department
visits for adverse drug events in older adults. Ann
Intern Med 2007;147:75565.
59. Hustey FM, Wallis N, Miller J. Inappropriate prescribing in an older ED population. Am J Emerg
Med 2007;25:8047.
60. Han JH, Wilber ST. Altered mental status in older
patients in the emergency department. Clin Geriatr
Med 2013;29:10136.
61. Holroyd-Leduc JM, Sands LP, Counsell SR, Palmer
RM, Kresevic DM, Landefeld CS. Risk factors for
indwelling urinary catheterization among older

346

62.

63.

64.

65.
66.

67.

68.

69.

70.

71.

72.

73.

74.

75.
76.

77.

78.

Hogan et al. ACUTE CARE IN AN AGING AMERICA

hospitalized patients without a specic medical indication for catheterization. J Patient Saf 2006;1:2017.
Carpenter CR. Evidence based emergency medicine/Rational Clinical Examination Abstract: Will
my patient fall? Ann Emerg Med 2009;53:398400.
Carpenter CR, Scheatzle MD, DAntonio JA, Ricci
PT, Coben JH. Identication of fall risk factors in
older adult emergency department patients. Acad
Emerg Med 2009;16:2119.
Sherman FT. The good news: its our 60th birthday.
The bad news: a giant, geriatric tsunami! Geriatrics
2006;61:1011.
Bodenheimer T. Primary carewill it survive? N
Engl J Med 2006;355:8614.
Roush RE, Tyson SK. Geriatric emergency preparedness and response workshops: an evaluation
of knowledge, attitudes, intentions, and self-efcacy
of participants. Disaster Med Public Health Prep
2012;6:38592.
Imamura T, Brown CA, Ofuchi H, et al. Emergency
airway management in geriatric and younger
patients: analysis of a multicenter prospective observational study. Am J Emerg Med 2013;31:1906.
Wang HE, Devlin SM, Sears GK, et al. Regional
variations in early and late survival after out-of-hospital cardiac arrest. Resuscitation 2012;83:13438.
Cairns CB, Maier RV, Adeoye O, et al. NIH roundtable on emergency trauma research. Ann Emerg
Med 2010;56:53850.
Wolinsky FD, Liu L, Miller TR, et al. Emergency
department utilization patterns among older adults.
J Geront Med Sci 2008;63A:2049.
Caplan GA, Williams AJ, Daly B, Abraham K. A
randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention
after discharge of elderly from the emergency
departmentThe DEED II study. J Am Geriatr Soc
2004;52:141723.
Pena ME, Snyder BL. Pediatric emergency medicine. The history of a growing discipline. Emerg
Med Clin North Am 1995;13:23553.
Cales RH, Trunkey DD. Preventable trauma deaths.
A review of trauma care systems development.
JAMA 1985;254:105963.
Institute of Medicine. Committee on the Future of
Emergency Care in the United States Health System. Future of Emergency Care: Emergency Care
for Children Growing Pains. Washington DC:
National Academies Press, 2007.
Editorial. Who cares for the elderly? Lancet
2008;371:959.
Ward RC, Mainiero MB. Graduate medical education in the era of health care reform. J Am Coll
Radiol 2013;10:70812.
The Joint Commission. Advanced Certication for
Primary Stroke Centers. Available at: http://www.
jointcommission.org/certication/
primary_stroke_centers.aspx. Accessed Dec 7, 2013.
Society of Cardiovascular Patient Care. Chest
Pain Accreditation. Available at: http://www.scpcp.
org/index.php/services/accreditation/chestpain.
Accessed Dec 7, 2013.

79. Adams R, Acker J, Alberts M, et al. Recommendations for improving the quality of care through
stroke centers and systems: an examination of
stroke center identication options: multidisciplinary consensus recommendations from the Advisory
Working Group on Stroke Center Identication
Options of the American Stroke Association. Stroke
2002;33:e17.
80. The Joint Commission reports high interest in new
certication program for comprehensive stroke centers. ED Manag 2012;24:1279.
81. Topol EJ, Kereiakes DJ. Regionalization of care for
acute ischemic heart disease: a call for specialized
centers. Circulation 2003;107:14636.
82. Jacobs AK, Antman EM, Faxon DP, Gregory T, Solis P. Development of systems of care for ST-elevation myocardial infarction patients: executive
summary. Circulation 2007;116:21730.
83. Graham K, Strauss C, Boland L, et al. Has the time
come for a national cardiovascular emergency care
system? Circulation 2012;125:203544.
84. Saver JL, Fonarow GC, Smith EE, et al. Time to
treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke.
JAMA 2013;309:24808.
85. Prabhakaran S, ONeill K, Stein-Spencer L, Walter
J, Alberts MJ. Prehospital triage to primary stroke
centers and rate of stroke thrombolysis. JAMA Neurol 2013;70:112632.
86. Rajamani K, Millis S, Watson S, et al. Thrombolysis
for acute ischemic stroke in Joint Commission-certied and -noncertied hospitals in Michigan. J
Stroke Cerebrovasc Dis 2013;22:4954.
87. Sampalis JS, Denis R, Lavoie A, et al. Trauma care
regionalization: a process-outcome evaluation. J
Trauma 1999;46:56579.
88. Haas B, Stukel TA, Gomez D, et al. The mortality
benet of direct trauma center transport in a regional trauma system: a population-based analysis. J
Trauma Acute Care Surg 2012;72: 15105.
89. Cudnik MT, Newgard CD, Sayre MR, Steinberg SM.
Level I versus Level II trauma centers: an outcomesbased assessment. J Trauma 2009;66:13216.
90. Lang ES, Wyer PC, Haynes RB. Knowledge translation: closing the evidence-to-practice gap. Ann
Emerg Med 2007;49:35563.
91. Watters JK, Biernacki P. Targeted sampling: options
for the study of hidden populations. Social Problems
1989;36:41630.
92. Heckathorn DD. Respondent driven sampling: a
new approach to the study of hidden populations.
Social Problems 1997;44:17499.
Supporting Information
The following supporting information is available in the
online version of this paper:
Data Supplement S1. The geriatric emergency
department survey instrument.
Data Supplement S2. Hospitals with conrmed
geriatric EDs.