The Geriatric Emergency Department
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The Geriatric Emergency
Department
Mark Rosenberg, DO, MBA, FACEP, FACOEP-D, FAAHPM
Associate Professor, Emergency Medicine,
New York Medical College, Valhalla, NY
Chairman, Department of Emergency Medicine
Medical Director, Population Health
St Joseph’s Healthcare System, Paterson , NJ
Innovations: GED, ED Palliative Care, ALTO, ED Population Health
Board of Directors, ACEP
Board of Directors EMF
1
St. Joseph’s Regional Medical Center
• 641-bed tertiary care teaching hospital
• Paterson, NJ
• Emergency Department - 2018
– 172,000 total visits/year:
• 41,000 Pediatric Emergency Department
• 28,000 Geriatric Emergency Department
• 24 Bed Unit
• 200 Emergency Department Palliative Medicine
• 2 LSMA Rooms
Comprehensive stroke center
Trauma center
Resuscitation center
Heart Failure center
Toxicology reference center
Life Sustaining Management and Alternatives (LSMA) 2
Making the Case for a Geriatric ED
3
Population >65 years by size and % of total population
4
ED utilization rates for seniors
• 7x more usage of ED services
• 43% of all admissions
• 48% of all Critical Care admissions
• 20% longer length of stay
• 50% more lab
• 50% more radiology
• 400% more social service interventions
CMS 2008 Data Set
5
The Geriatric ED Difference
6
A GED is Designed for the Functionally Independent
Healthy Controlled Health Issues
• Feel great • MI within past two years
• Exercise daily • High BP
• Eat right • High cholesterol
• Drink socially • Prostate Cancer
• Very social • Osteoarthritis
• On six medications
• Countless vitamins
• Contact lenses
• Hearing aids
7
Two paradigms
Non-geriatric ED Patient Geriatric ED Patient
Single complaint Multiple problems
Medical
Functional
Social
Acute Acute on chronic, subacute
Diagnose and treat Control symptoms,
maximize function,
enhance quality of life
Rapid disposition Continuity of care
8
The Geriatric Patient Encounter
• Mrs. Smith is a 78 y/o functionally
independent senior. She lives alone and
daughter lives 2 blocks away.
• This AM, Mrs. Smith hurt her ankle going
down the steps. Has difficulty ambulating.
9
The Geriatric ED Difference
The GED Difference
Adult ED Geriatric ED
• H and P • H and P
• Order X-Ray • Order X-Ray
10The Geriatric ED Difference
The GED Difference
Adult ED Geriatric ED
• H and P • H and P
• Order X-Ray • Order X-Ray
• Reevaluation
• Discharge
11The Geriatric ED Difference
The GED Difference
Adult ED Geriatric ED
• H and P • H and P
• Order X-Ray • Order X-Ray
• Reevaluation • Seen by GED Team
• Discharge • PT
• Social Work
• Nutrition
• Geri RN
• Pharmacy
• Geriatric Screenings
• Discharge Planning
• Transition of Care
12The Geriatric ED Difference
The GED Difference
Adult ED Geriatric ED
• H and P • H and P
• Order X-Ray • Order X-Ray
• Reevaluation • Seen by GED Team
• Discharge • PT
• Social Work
• Nutrition
• Geri RN
• Pharmacy
• Geriatric Screenings
• Discharge Planning
• Transition of Care
13
• Home AssessmentThe Geriatric ED Difference
The GED Difference
Adult ED Geriatric ED
• H and P • H and P
• Order X-Ray • Order X-Ray
• Reevaluation • Seen by GED Team
• Discharge • PT
• Social Work
• Nutrition
• Geri RN
Also Senior Patient Has • Pharmacy
Phone Reassessment • Geriatric Screenings
on Day 1,3, 7, and • Discharge Planning
day 30 • Transition of Care
14
• Home AssessmentOutcomes
• Increased patient satisfaction
• Higher rate of postdischarge independence
• Fewer return visits
• Lower admission and readmission rate
• Improved screening for inappropriate medications
• Increased patient volume
15The GED Guidelines
16Nationally
More than 180 Geriatric EDs and growing…
…finally there is a standard.
Accreditation Standard and Minimal Requirements Development…
• ACEP
• AGS
• ENA JCAHO and DNV
• SAEM
1718
19
20
Geriatric ED Accreditation
21Why
• If not us then who?
• Makes your job easier - Members
• Better care for seniors – Patients
• Better for ACEP
• Where would you want your mom to go…
227 Domains
of a GED
2324
25
26
2. Quality initiatives
1. FALLS ASSESSMENT and PREVENTION
• Falls risk assessment
• Get-up-and-go testing
2. MEDICATIONS
• Drug interactions
• 5 Meds = 70% chance of drug interactions
• 7 Meds = 100% chance of drug interaction
• Beers criteria
• AGS 2012
• Potentially inappropriate medication use in older adults
3. GERIATRIC SCREENING
• Dementia, Delirium, Depression, Nutrition, Falls
• ISAR
278. Patient Satisfaction/Value Based Purchasing
• Address Patient by preferred name
• Patient liaison
– Blankets
– Reading glasses
– Hearing assist devices
• Nutrition
– Food
– Snacks
– Coffee and Tea
• Space for Family
• Holistic Medicine
28Holistic Medicine
• Reiki Energy
http://www.youtube.com/watch?v=m3 d4qGZ5 Bzo&fea ture=pl ayer_d etailpa ge#t=3 5s
• Pranic Healing Energy
• Aroma Therapy
http://www.youtube.com/watch?v=8tD IDpscnLw&feat ure=pla yer_de tailpag e
• Acupressure
• Music Therapy
• Medical Harp Therapy
• Light Therapy
http://www.youtube.com/watch?v=1NRixtN6jY M
29Putting it all together
Evelyn and Stanley’s Story
91+88=Priceless
30Three Day Later on a Date…....
Stanley’s Story….. House Sitting Pet Sitting Minor Home Repairs
The Downward Spiral
• Depression
• Weight Loss
• More Injury
• Role of the Geriatric ED
– Strength
– Nutrition
– Palliative Care
• HospiceWe All Have Goals…..
Please, Can We Dance AgainAdd 6 People
4 Cars
2 Wheel Chairs
One Walker
Two Canes
One Doctor
38One Year Latter • Evelyn – Weight – Independent • Stanley – Driving
The Geriatric ED!
If not us then who?
The Time is Now!The GED Team
42This is dedicated to the ones we love
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