Do you sometimes have the uneasy sense that something in the emergency department where you work needs to change? Does this feeling stem from the treatment of older patients? Do you hear comments like, “Is it my imagination, or are there lots more old people around?” or “there are so many complaints from older patients” or “why is it that looking after older people in the ED is so hard?”
If any of those comments echo what you’re thinking and hearing in your ED, this book’s for you. We speak directly to you and other ED clinicians, administrators, and hospital leaders who want practical guidance about how to improve their ED’s care of older people. We want to provide you with immediately applicable information and even a road map to start improving care of your older patients. In this book we offer a guide that’s both evidence-based and experience-based. We’ve packed it with actionable information to give you ideas about how to change your ED’s structures, processes, and outcomes. And we’ve organized it to provide a step-by-step framework for any ED, large or small, to assess and address its readiness, staffing, processes, equipment, resources, and space as it seeks to improve the ED care of older people.
This book grows out of the authors’ experience – 60 years between the two of us – of working in the field of Geriatric Emergency Medicine (EM). Don Melady has been an emergency physician for 30 years. During his whole career as a clinician and educator, he’s taken an active interest in how he can improve his own care of older people and how systems of care can be changed to do the same. Based at Mount Sinai Hospital, University of Toronto, Canada, he is the founding chair of the Geriatric EM Committee at the International Federation of Emergency Medicine. John Schumacher has been a bioethicist and medical sociologist for 30 years, focusing on EDs and researching the care provided to older people. His career has concentrated on improving the interactions between physicians, older patients, and the settings in which they take place. He has consulted on the creation and operation of numerous Geriatric EDs as a faculty member based at the University of Maryland, Baltimore County (UMBC), USA.
Our book has also benefitted from contributions, suggestions, comments, and good advice from our colleagues around the world, an international list of Geriatric ED authorities – nurses, doctors, and academics who focus their practice on improving care of the older ED patient.
It’s no secret that in almost every country of the world, the population of older adults is rising steeply [1]. Not surprisingly, these demographics link to an increase in the number of older people in EDs across the world. We know that EDs have treated older patients since their inception, accumulating extensive experience with this patient population. However, while we have seen significant practice advances in the area of Geriatric Emergency Medicine over the past 30 years, many of them have not been integrated into mainstream ED practice. In fact, relatively few EDs have made any of the systematic changes described here to prepare for the growing number of older ED patients. Empirical research is slowly emerging. And experience suggests that EDs implementing changes like those in The Geriatric ED Guidelines [Reference Carpenter, Bromley and Caterino2] or the European Geriatric Emergency Medicine Curriculum [Reference Bellou, Nickel and Martín-Sánchez3] report consistent improvements in outcomes, better functioning, reduced costs, and higher staff satisfaction.
This book is aimed at helping practicing ED interdisciplinary clinicians, ED leaders, and hospital administrators who are responsible for providing acute care to older adults. Colleagues who are involved in quality improvement and continuing education programs may benefit from much of its focused content and suggestions. Hospitals involved in graduate medical education for emergency medicine and emergency nursing may find this book a valuable resource for programming. Finally, hospitals considering accreditation by the American College of Emergency Physician’s Geriatric ED Accreditation (GEDA) body (www.acep.org/geda/) may find this book a helpful resource.
We recognize that EDs are highly varied, both nationally and internationally. We have organized the nine chapters of this book to transcend the structure of any single ED or medical system with an eye to providing guidance that can be tailored to any ED. We want to provide a brief evidence- and experience-informed practical guide to get you started on improving your ED’s care of older people.
We start with the first chapter titled “Making the Case for a Geriatric Emergency Department.” First of all, we clarify that a Geriatric ED refers to any general ED that is making changes to improve the care it provides its older patients. We give you some rationale for making this change to convince your hospital’s leadership and provide you with some evidence and scripts to use when pitching the idea. Chapter 2, “Starting a Geriatric Emergency Department,” gets into the nuts and bolts of the first steps of assessing your current ED, identifying your allies, and exploring different models of Geriatric EDs. In Chapter 3, “Overcoming Resistance: What to Do With ‘Yeah, But …” we share practical strategies for addressing the push-back you may get from pioneering a Geriatric ED.
Chapters 4, 5, 6, and 7 are the core of the book’s “practical guide,” with lots of information and suggestions about how things can be different in a Geriatric ED. Chapter 4, “You: An Approach to Your Older Emergency Department Patients,” describes some key changes that clinicians may want to adopt or adapt in their approach to older people.
Chapters 5, 6, and 7 introduce the Geriatric ED’s 3 Ps of people, processes, and place. Chapter 5, “People: Adding Staffing and Training,” examines the staff roles necessary to implement a Geriatric ED including the central Geriatric ED nurse care coordinator role. Then Chapter 6, “Processes: Implementing Protocols and Policies,” presents the wide range of process changes that could be made as part of a Geriatric ED. The focus of Chapter 7, “Place: Addressing the Physical Environment,” is the small additions and changes you can make to geriatricize your ED, as well as the large reconfigurations of the physical space.
Chapter 8, entitled “Quality Improvement in the Geriatric Emergency Department: Getting Started,” provides an introduction to integrating quality improvement efforts into the Geriatric ED. Our conclusion, Chapter 9, “Launching Your Geriatric Emergency Department: From First Steps to Accreditation,” encourages you to take action and begin your efforts to improving care for older adults in the ED. The Appendix includes references to commonly used assessment tools, model policies, and a list of adaptations to the physical environment used by Geriatric EDs around the world.
Throughout the book, we’ve provided personal accounts from many different EDs internationally to put a human face on Geriatric ED change. They are stories from people working in big cities, small towns, and academic and community hospitals around the globe about how and why they got started on this journey and about the outcomes they have seen.
Overall, this book is designed as a practical guide for interested ED people who want tips, tricks, ideas, and suggestions based on evidence and experience for better ways to organize their EDs to measurably improve care of the rapidly growing population of older ED patients.
Our ardent hope is that the insights we offer will make your life as a clinician better, and that, as a consequence, your older patients will get even better care than they already do.
