‘Geriatric’ Emergency Department - emergency medicine in evolution
We all know that the world is growing older – it is now common for emergency department (ED) clinicians to spend the majority of their day looking after frail older adults.
In emergency medicine (EM) we are going through a ‘longish’ period of reflection on how best to care for older adults (EM is just over 40 years old, and for 30 of those years there has been discussion about this). Interest in the needs of frail older adults has widened and many solutions have been tried in EDs worldwide, with mixed results. These include rapid response teams, liaison geriatrics, interface geriatrics and the development of seniors EDs.
There are many reasons why EDs and emergency clinicians are not meeting the needs of older adults. The physical environment is designed to maximise throughput of patients – cubicles are close together and filled with handy things you might need, patients are moved through different areas of the ED for different processes to occur – triage/rapid assessment/majors/resus. There are about seven places one might be sent from triage, and for most people there will be two to three transitions of care whilst in the ED.
It is chaotic, cluttered, noisy, and busy; people are constantly moving around, the corridors and free floor space often double up as trolley bays; police come, people shout, people cry, babies scream, alarms herald the arrival of the unstable, and machines hum and buzz constantly. This is my environment and the one in which my kind thrive – however I understand why everyone apart from the species known as ‘interface geriatrician’ dodges the ED! How, you ask, is anyone meant to make a decision here? How is anyone not meant to get delirious after four hours of sitting here?
Patients may also get ‘inappropriately’ referred on the clinical decision units, frailty units and even to on-call teams where there is more time to make phone calls to GPs, relatives, social workers, care agencies and find the kindly neighbour who is minding the keys but doesn’t have a mobile and was out shopping all day. Time is also needed to get the key safe installed and the door fixed (having been knocked down to access an immobile patient). In the target-driven world in which I live, this is almost impossible – I need to have the patient seen within 1.5 hours and a disposition decision made within 2.5 hours of arrival. That is why decisions are sometimes made in haste.
So what is the solution? The debate in geriatric EM at the moment is whether we should make all EDs “frail-friendly”, or whether we should develop dedicated departments for frail older adults. Before I say more about this I want you to think about paediatric EM. Paediatric EDs are a new thing – during my training I mostly worked in mixed departments where all comers were seen together. The debate on needing to separate paediatric from adults department was won (slowly) by pointing out, quite simply, that children had differing physical, psychological and social needs compared to adults. They require both nursing and medical expertise focused on these needs and paediatric pathology so that accurate diagnosis and safe discharge decisions are being made. Separating children both visibly and audibly from the adult department was seen to be important in reducing distress and risk to this vulnerable group. Now few of us would dream of pitching up to our local ED with a small child to be seen by a clinician with no paediatric experience in an adult department.
I suggest that all these arguments hold true for frail older adults – creating discrete departments for them allows us to cohort expertise, provide a more appropriate environment for caring for those that are frail, and one in which we are able to meet the psychological needs of older adults, particularly those with cognitive impairment.
Geriatric EDs won’t replace frailty units – which effectively function as short-stay wards in the same vein as clinical decisions units or medical assessment units. Care will move further towards the beginning of a patient’s journey and this may divert admissions and allow for better integration of services, both in the community and within the hospital.
We have been thinking about this for a long time, and in that time the demand for and complexity of care delivered in the ED has increased. It is time for a bespoke solution for older adults using our emergency services, which is focused around their needs – a geriatric ED.