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Background: The Geriatric Emergency Department (ED) Guidelines recommend screening older patients for need for evaluation by geriatric medicine, physical therapy (PT), and occupational therapy (OT), but explicit evidence that geriatric screening changes care compared to physician gestalt is lacking. We assessed changes in multidisciplinary consultation after implementation of standardized geriatric screening in the ED., Methods: Retrospective single-site observational cohort of older adult ED patients from 2019 to 2023 with three time periods: (1) preimplementation, (2) implementation of geriatric screening, and (3) postimplementation. Geriatric, PT, and OT consultations/referrals were available during all time periods. Descriptive analysis was stratified by disposition: discharged, observation and discharged, observation and hospital admission, and hospital admission. The independent variable was completion of three geriatric screening tools by ED nurses. The dependent variable was consultation and/or referral to geriatrics, PT, and OT. Secondary outcomes were disposition, ED revisits, and 30-day rehospitalizations., Results: There were 57,775 qualifying ED visits of patients age ≥ 65 years during the time periods: implementation increased geriatric screening from 0.5% to 63.2%; postimplementation, discharge patients who received screening had more consultations/referrals to geriatrics (1.5% vs. 0.4%), PT (7.9% vs. 1.9%), and OT (6.5% vs. 1.2%) compared to unscreened patients. Patients observed and then discharged had more consultations/referrals to geriatrics (15.1% vs. 11.3%), PT (74.1% vs. 64.5%), and OT (65.7% vs. 56.5%). Admitted patients had no change in consultation rates. Geriatric screening was not associated with a change in 7-day ED revisits for discharged patients but was associated with decreased revisits for patients discharged from observation (11.6% vs. 42.9%, p < 0.001)., Conclusion: Geriatric screening was associated with increased consultations/referrals to geriatrics, PT, and OT in the ED and ED observation unit. This suggests that geriatric screening changes ED care for older adults., (© 2024 The Author(s). Academic Emergency Medicine published by Wiley Periodicals LLC on behalf of Society for Academic Emergency Medicine.)

Background: The Geriatric Emergency Department (ED) Guidelines recommend screening older adults during their ED visit for delirium, fall risk/safe mobility, and home safety needs. We used the Consolidated Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementation Change (ERIC) tool for preimplementation planning., Methods: The cross-sectional survey was conducted among ED nurses at an academic medical center. The survey was adapted from the CFIR Interview Guide Tool and consisted of 21 Likert scale questions based on four CFIR domains. Potential barriers identified by the survey were mapped to identify recommended implementation strategies using ERIC., Results: Forty-six of 160 potential participants (29%) responded. Intervention Characteristics: Nurses felt geriatric screening should be standard practice for all EDs (76.1% agreed some/very much) and that there was good evidence (67.4% agreed some/very much). Outer setting: The national and regional practices such as the existence of guidelines or similar practices in other hospitals were unknown to many (20.0%). Nurses did agree some/very much (64.4%) that the intervention was good for the hospital/health system. Inner Setting: 67.4% felt more staff or infrastructure and 63.0% felt more equipment were needed for the intervention. When asked to pick from a list of potential barriers, the most commonly chosen were motivational (I often do not remember (n = 27, 58.7%) and It is not a priority (n = 14, 30.4%)). The identified barriers were mapped using the ERIC tool to rate potential implementation strategies. Strategies to target culture change were identifying champions, improve adaptability, facilitate the nurses performing the intervention, and increase demand for the intervention., Conclusion: CFIR domains and ERIC tools are applicable to an ED intervention for older adults. This preimplementation process could be replicated in other EDs considering implementing geriatric screening., (© 2021 The American Geriatrics Society.)

Objectives: The American College of Emergency Physicians' geriatric emergency department (GED) guidelines recommend additional staff and geriatric equipment, which may not be financially feasible for every ED. Data from an accredited Level 1 GED was used to report equipment costs and to develop a business model for financial sustainability of a GED., Methods: Staff salaries including the cost of fringe benefits were obtained from a Midwestern hospital with an academic ED of 80,000 annual visits. Reimbursement assumptions included 100% Medicare/Medicaid insurance payor and 8-hour workdays with 4.5 weeks of leave annually. Equipment costs from hospital invoices were collated. Operational and patient safety metrics were compared before and after the GED., Results: A geriatric nurse practitioner in the ED is financially self-sustaining at 7.1 consultations, a pharmacist is self-sustaining at 7.7 medication reconciliation consultations, and physical and occupational therapist evaluations are self-sustaining at 5.7 and 4.6 consults per workday, respectively. Total annual equipment costs for mobility aids, delirium aids, sensory aids, and personal care items for the GED was $4,513. Comparing the 2 years before and after, in regard to operational metrics the proportions of patients with lengths of stay > 8 hours and patients placed in observation did not change. In regard to patient safety, the rate of falls decreased from 0.60/1,000 patient visits to 0.42/1,000 in the ED observation unit and 0.42/1,000 to 0.36/1,000 in the ED. ED recidivism at 7 and 30 days did not change. Estimated cost savings from the reduction in falls was $80,328., Conclusion: The additional equipment and personnel costs for comprehensive geriatric assessment in the ED are potentially financially justified by revenue generation and improvements in patient safety measures. A geriatric ED was associated with a decrease in patient falls in the ED but did not decrease admissions or ED recidivism., (© 2020 by the Society for Academic Emergency Medicine.)

In 2018, the American College of Emergency Physicians (ACEP) began accrediting facilities as "geriatric emergency departments" (EDs) according to adherence to the multiorganizational guidelines published in 2014. The guidelines were developed to help every ED improve its care of older adults. The geriatric ED guideline recommendations span the care continuum from out-of-hospital care, ED staffing, protocols, infrastructure, and transitions to outpatient care. Hospitals interested in making their EDs more geriatric friendly thus face the challenge of adopting, adapting, and implementing extensive guideline recommendations in a cost-effective manner and within the capabilities of their facilities and staff. Because all innovation is at heart local and must function within the constraints of local resources, different hospital systems have developed implementation processes for the geriatric ED guidelines according to their differing institutional capabilities and resources. This article describes 4 geriatric ED models of care to provide practical examples and guidance for institutions considering developing geriatric EDs: a geriatric ED-specific unit, geriatrics practitioner models, geriatric champions, and geriatric-focused observation units. The advantages and limitations of each model are compared and examples of specific institutions and their operational metrics are provided., (Copyright © 2019 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: The Geriatric Emergency Department (ED) Guidelines recommend providing multidisciplinary geriatric assessment in the ED, but these assessments can be difficult to coordinate and may prolong length of stay. Patients who need longer than a typical ED stay can be placed in an ED observation unit (Obs Unit). We investigated the effects of offering multidisciplinary assessments for ED patients in an Obs Unit., Methods: Evaluation by a geriatric hospital consultation team, physical therapist, case manager, and/or pharmacist was made available to all Obs Unit patients. Use of any or all of these ancillary consult services could be requested by the Obs Unit physician. A retrospective chart review of random older adult Obs Unit patients was done to assess rates of consult use and interventions by these consulting teams. All patients ≥ 65 years old in our institutional review board-approved, monthly Obs Unit quality database from October 2015 through March 2017 were included., Results: Our quality database included 221 older patients over 18 months. The mean (±SD) age was 73.3 (±6.8) years (range = 65-96 years) and 55.2% were women. The mean (±SD) observation length of stay was 14.7 (±6.5) hours. The majority (74.3%) were discharged from the Obs Unit and 72-hour ED recidivism was 3.6%. Overall, at least one of the multidisciplinary consultant services were requested in 40.3% of patients (n = 89). Additional interventions or services were recommended in 80.0% of patients evaluated by physical therapy (32 of 40 patients), 100% of those evaluated by a pharmacist (five of five patients), 38% of those evaluated by case management (27 of 71 patients), and 100% of those evaluated by a geriatrician (eight of eight patients). Only 5.4% (n = 12) of patients were placed in observation specifically for multidisciplinary assessment; these patients had a mean (±SD) length of stay of 12.2 (±5) hours and an admission rate of 41.7%., Conclusions: Incorporating elements of multidisciplinary geriatric assessment for older patients is feasible within an observation time frame and resulted in targeted interventions. An Obs Unit is a reasonable setting to offer services in compliance with the Geriatric ED Guidelines., (© 2017 by the Society for Academic Emergency Medicine.)

Background: The American College of Surgeons' Trauma Quality Improvement Program (TQIP) Geriatric Trauma Management Guidelines recommend geriatric consultation for injured older adults. However it is not known how or whether geriatric consultation improves compliance to these quality measures., Methods: This study is a retrospective chart review of our institutional trauma databank. Adherence to quality measures was compared before and after implementation of specific triggers for geriatric consultation. Secondary analyses evaluated adherence by service: trauma service (Trauma) or a trauma service with early geriatric consultation (GeriTrauma)., Results: The average age of the 245 patients was 76.7 years, 47% were women, and mean Injury Severity Score was 9.5 (SD ±8.1). Implementation of the GeriTrauma collaborative increased geriatric consultation rates from 2% to 48% but had minimal effect on overall adherence to TQIP quality measures. A secondary analysis comparing those in the post implementation group who received geriatric consultation (n = 94) to those who did not (n = 103) demonstrated higher rates of delirium diagnosis (36.2% vs 14.6%, P < 0.01) and better documentation of initial living situation, code status, and medication list in the GeriTrauma group. Physical therapy was consulted more frequently for GeriTrauma patients (95.7% vs 68.0%, P < 0.01) Documented goals of care discussions were rare and difficult to abstract. A subgroup analysis of only patients with fall-related injuries demonstrated similar outcomes., Conclusions: Early geriatric consultation increases adherence to TQIP guidelines. Further research into the long term significance and validity of these geriatric trauma quality indicators is needed., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: The American College of Emergency Physicians Geriatric Emergency Department (ED) Guidelines and the Center for Disease Control recommend that older adults be assessed for risk of falls. The standard ED assessment is a verbal query of fall risk factors, which may be inadequate. We hypothesized that the addition of a functional balance test endorsed by the Center for Disease Control Stop Elderly Accidents, Deaths, and Injuries Falls Prevention Guidelines, the 4-Stage Balance Test (4SBT), would improve the detection of patients at risk for falls., Methods: Prospective pilot study of a convenience sample of ambulatory adults 65 years and older in the ED. All participants received the standard nursing triage fall risk assessment. After patients were stabilized in their ED room, the 4SBT was administered., Results: The 58 participants had an average age of 74.1 years (range, 65-94), 40.0% were women, and 98% were community dwelling. Five (8.6%) presented to the ED for a fall-related chief complaint. The nursing triage screen identified 39.7% (n=23) as at risk for falls, whereas the 4SBT identified 43% (n=25). Combining triage questions with the 4SBT identified 60.3% (n=35) as at high risk for falls, as compared with 39.7% (n=23) with triage questions alone (P<.01). Ten (17%) of the patients at high risk by 4SBT and missed by triage questions were inpatients unaware that they were at risk for falls (new diagnoses)., Conclusions: Incorporating a quick functional test of balance into the ED assessment for fall risk is feasible and significantly increases the detection of older adults at risk for falls., Competing Interests: None reported., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The article presents a study which described the prevalence of acute decline in ability to perform activities of daily living (ADL) in older adults presenting to the emergency department (ED) with suspected pneumonia. Topics discussed include demographic characteristics of older ED patients with suspected pneumonia, and limitations of the study, and the need of emergency physicians to evaluate for acute decline during their treatment and disposition decisions.

Background: Geriatric emergency department (GED) guidelines endorse screening older patients for geriatric syndromes in the ED, but there have been significant barriers to widespread implementation. The majority of screening programs require engagement of a clinician, nurse, or social worker, adding to already significant workloads at a time of record‐breaking ED patient volumes, staff shortages, and hospital boarding crises. Automated, electronic health record (EHR)‐embedded risk stratification approaches may be an alternate solution for extending the reach of the GED mission by directing human actions to a smaller subset of higher risk patients. Methods: We define the concept of automated risk stratification and screening using existing EHR data. We discuss progress made in three potential use cases in the ED: falls, cognitive impairment, and end‐of‐life and palliative care, emphasizing the importance of linking automated screening with systems of healthcare delivery. Results: Research progress and operational deployment vary by use case, ranging from deployed solutions in falls screening to algorithmic validation in cognitive impairment and end‐of‐life care. Conclusions: Automated risk stratification offers a potential solution to one of the most pressing problems in geriatric emergency care: identifying high‐risk populations of older adults most appropriate for specific GED care. Future work is needed to realize the promise of improved care with less provider burden by creating tools suitable for widespread deployment as well as best practices for their implementation and governance. [ABSTRACT FROM AUTHOR]

Objective: Implementation of evidence‐based care processes (EBP) into the emergency department (ED) is challenging and there are only a few studies of real‐world use of theory‐based implementation frameworks. We report final implementation results and sustainability of an EBP geriatric screening program in the ED using the Consolidated Framework for Implementation Research (CFIR). Methods: The EBP involved nurses screening older patients for delirium (Delirium Triage Screen), fall risk (4‐Stage Balance Test), and vulnerability (Identification of Seniors at Risk score) with subsequent appropriate referrals to physicians, therapy specialists, or social workers. The proportions of screened adults ≥65 years old were tracked monthly. Outcomes are reported January 2021–December 2022. Barriers encountered were classified according to CFIR. Implementation strategies were classified according to the CFIR‐Expert Recommendations for Implementing Change (ERIC). Results: Implementation strategies increased geriatric screening from 5% to 68%. This did not meet our prespecified goal of 80%. Change was sustained through several COVID‐19 waves. Inner setting barriers included culture and implementation climate. Initially, the ED was treated as a single inner setting, but we found different cultures and uptake between ED units, including night versus day shifts. Characteristics of individuals barriers included high levels of staff turnover in both clinical and administrative roles and very low self‐efficacy from stress and staff turnover. Initial attempts with individualized audit and feedback were not successful in improving self‐efficacy and may have caused moral injury. Adjusting feedback to a team/unit level approach with unitwide stretch goals worked better. Identifying early adopters and conducting on‐shift education increased uptake. Lessons learned regarding ED culture, implementation in interconnected health systems, and rapid cycle process improvement are reported. Conclusions: The pandemic exacerbated barriers to implementation in the ED. Cognizance of a large ED as a sum of smaller units and using the CFIR model resulted in improvements. [ABSTRACT FROM AUTHOR]

Background: The Institute for Healthcare Improvement's 4‐Ms framework of care for older adults recommends a multidisciplinary assessment of a patient's Medications, Mentation, Mobility, and What Matters Most. Electronic health record (EHR) systems were developed prior to this emphasis on the 4‐Ms. We sought to understand how healthcare providers across the healthcare system perceive their EHRs and to identify any current best practices and ideas for improvement regarding integration of the 4‐Ms. Methods: Anonymous survey of healthcare providers who care for older adults. The survey aimed to evaluate efficiency, error tolerance, and satisfaction (usefulness and likeability). The survey was distributed through organizational list serves that focus on the care of older adults and through social media. Results: Sixty‐six respondents from all geographic segments of the U.S. (n = 62) and non‐U.S. practices (n = 4) responded. Most (82%) were physicians. Respondents used a range of EHRs and 82% had >5 years of experience with their current EHR. Over half of respondents agreed that their EHR had easy to find contact information (56%) and advance directives. Finding a patient's prior cognitive status (26% agreement), goals of care (24%), functional status (14%), and multidisciplinary geriatric assessments (27%) was more difficult. Only 3% were satisfied with how their EHR handles geriatric syndromes. In free text responses, respondents (79%) described three areas that the EHR assists in the care of older adults: screening tied to actions or orders; advance care planning, and medication alerts or review. Common suggestions on how to improve the EHR included incorporating geriatric assessments in notes, establishing a unified place to review the 4‐Ms, and creating age‐specific best practice alerts. Conclusions: The majority of healthcare providers were not satisfied with how their EHR handles multidisciplinary geriatric assessment and geriatric care. EHR modifications would aide in reporting, communicating, and tracking the 4‐Ms in EHRs. [ABSTRACT FROM AUTHOR]