Eductional Resources

Enhancing Older Adult Emergency Care:  Introducing the American College of Emergency Physicians/American Geriatrics Society/Emergency Nurses Association/Society for Academic Emergency Medicine Geriatric Emergency Department Guidelines

Christopher R. Carpenter, MD, MSc (Chair, ACEP Geriatric Section)

In October 2013, the American College of Emergency Physicians and Society for Academic Emergency Medicine Boards of Directors officially approved the Geriatric Emergency Department Guidelines (see website).  These guidelines represent recommendations for geriatric adult emergency care and add to those previously provided by the British Geriatrics Society entitled The Silver Book.  The guideline authors are practicing emergency physicians and the intent of this work is to help nurses, clinicians, hospital administrators, and health care systems to optimize geriatric emergency care within their institution based upon patient needs and available resources.  We anticipate many questions and concerns related to these recommendations so this introduction is meant to help ICEG members to understand these new recommendations.
1)    Why now?  
2)    How were these guidelines derived?
3)    What are the GED Guidelines?
4)    What is next?

Emergency Geriatrics – The United States Experience

In 1990 America, emergency medicine had no geriatric emergency care interest groups, textbooks, or dedicated mentors.  Very little research existed to understand the unique needs or ED management related outcomes of this population.  The demographic imperative of a rapidly aging baby-boomer society was sluggish to awaken change in geriatric emergency medicine.  During this period, the John A. Hartford Foundation decided to focus on improving geriatric health care outcomes.  Recognizing the cross-disciplinary role of emergency medicine, they approached UAEM, the precursor of SAEM with a challenge to develop a body of expertise in geriatric emergency medicine education, research, clinical operations, and policy-making.  This resulted in the formation of the first Geriatric Emergency Medicine Task Force in 1991 and an entire issue of Annals of Emergency Medicine dedicated to geriatric emergencies in 1992.  These manuscripts described the current state of affairs for geriatric emergency care while outlining an agenda for future research and educational initiatives.  The energy and productivity of this first Task Force led to a larger grant from the Hartford Foundation in 1993 that ultimately led to the first textbook (Emergency Care of the Elder Person in 1996), as well as multiple research projects that further defined the epidemiology of geriatric syndromes in the ED (falls, delirium, dementia, polypharmacy).  

In 2000, the Geriatric Interest Group (now Academy for Geriatric Emergency Medicine) was born at SAEM followed soon thereafter by the ACEP Geriatric Section in 2003.  These geriatric emergency medicine groups came to the realization that abstract presentations, traditional CME lectures, manuscripts, and textbooks alone were insufficient to align emergency care of older adults with geriatric management principles.  Emergency medicine needed a structured document containing best practice recommendations from geriatric emergency care health care providers, researchers, and advocates.  Consequently, work on the GED Guidelines began in 2011.

Deriving the GED Guidelines
Leaders within the ACEP Geriatric Section and AGEM identified representatives from ACEP, AGS, ENA, and SAEM organized a series of teleconferences during the years 2011 and 2012.  The 14 GED Guidelines co-authors split into two working groups:  “structural and staffing” and “clinical/operational”.  Each group reviewed the literature and provided best-evidence recommendations for essential geriatric emergency care.  Between October 2013 and February 2014, ACEP, SAEM, AGS, and ENA Boards of Directors officially approved the guidelines and on February 14 2014, they were posted online for ICEG members.

Components of the GED Guidelines – Perceptions and Realities
The Geriatric ED Guidelines consist of 40 specific recommendations in six general categories:  Staffing, Transitions of Care, Education, Quality Improvement, Equipment/Supplies, and Policies/Procedures/Protocols.The GED Guidelines are not intended for every community in the world to open geriatric-only EDs.  Most health care systems lack the financial resources, staffing levels, or patient volumes for stand-alone geriatric EDs to be feasible. The guidelines are not an authoritarian dictate for every ED to develop and sustain all of these elements. However, every ED that provides emergency care for geriatric adults ought to be aware of these guidelines, the rationale for the recommendations, and the resources available to transition from theory to implementation.

The Future of Geriatric Emergency Care
These guidelines represent a two-year effort from multiple organizations and individuals committed to optimizing the emergency care delivery model for geriatric adults.  We believe that the geriatric adult in the ED represents the “canary in the coal mine” for our health care system.  If we can successfully navigate the challenges that this vulnerable population presents to 21st Century medicine than all age groups will benefit from a reliably available, compassionate, and efficient emergency care system.  However, we fully recognize that the GED Guidelines are a beginning not an end so the authors lay out a plan forward that includes dissemination, implementation, adaptation, and refinement.  

• More research.  The empiric basis for our recommendations are based on rather weak research evidence in most cases so sustainable funding opportunities are needed to enhance the evidentiary basis of these protocols, as well as the pool of future geriatric emergency medicine thought leaders.  
• Prioritization.  The 40 recommendations need stratification into essential and non-essential domains so that hospital administrators, payers, and research funders can develop a systematic approach to local implementation.  
• Raising Awareness.  Emergency medicine clinicians, hospital administrators, patient advocacy leaders, and patients should be aware that the GED guideline exist.  However, adult learning theory and implementation science indicate that hands-on learning is simultaneously more desirable for learners and effective in terms of sustained practice change.  Therefore, the guideline group is also developing a “Geriatric Emergency Department Boot Camp” program in which geriatric emergency medicine leaders bring the recommendations, a toolbox of resources, pragmatic examples from their own institutions, and mentorship to interested programs so that nurse- and clinician-providers do not need to travel and essential ancillary providers like social work, case management, consultants, hospital administrators, and payers can also participate.  The intent is for participants in the boot camps to devise quality improvement projects with which the boot camp faculty will assist and for which one-year outcomes will be assessed.  
• Refinement.  The boot camp concept also provides a tangible test tube to evaluate the feasibility, acceptability, and barriers to existing GED Guideline recommendations – knowledge that will be used to refine the 2nd Edition of GED Guidelines in coming years.