key: cord-0756868-jjup3ro3
authors: Hunt, Lauren J.
title: Improving care for older adults in the Emergency Department warrants greater investment in geriatric nursing—Stat!
date: 2020-04-13
journal: Geriatr Nurs
DOI: 10.1016/j.gerinurse.2020.04.011
sha: bbafaf3a48abc3dfcd1954ae95d03bc961de1e8f
doc_id: 756868
cord_uid: jjup3ro3

Abstract Older adults use the Emergency Department (ED) more than any other age group besides infants. Despite high utilization, both the physical environment and care processes in the traditional ED are poorly suited to address the complex needs of older adults. As a result, older adults often experience poor outcomes in the ED. Geriatric nursing has been at the forefront of efforts to develop Geriatric Emergency Department Interventions (GEDI's) to try to address these deficits and improve care. As frontline providers with frequent patient contact, nursing brings critical viewpoints to these issues. This article provides some resources and other ideas for how frontline nurses can improve care for older adults in the ED. Ultimately, to have meaningful impacts on care of older adults in the ED, there is a dire need for greater financial investment specific to geriatric nursing education, training, and research in the ED.

The recent COVID-19 pandemic, with its high infection and death rates among older adults, has underscored just how critical the role of the Emergency Department (ED) is in the care of older adults. But even in "normal" times, older adultsÀparticularly the oldest old and those with underlying health conditionsÀfrequently rely on the ED for care. In the United States (U.S.), older adults account for over 15% of the almost 150 million visits to the ED annually. Older adults in the ED tend to have a higher level of medical urgency, are more likely to undergo extensive diagnostic testing, have longer stays in the ED, and are more likely to be admitted to the hospital subsequent to the ED visit. 1 These statistics are even more stark for older adults with additional vulnerabilities, such as older adults with dementia. 2 Despite their high utilization of the ED, the traditional ED environment is poorly suited to address the complex needs of older adults. Both the physical design and the processes of care in the ED are designed for the purpose of rapid triage and diagnosis-goals which are not necessarily aligned with the characteristics and needs of older adults. 3 For example, equipment crowded into a small exam area and slippery linoleum floors increase fall risk for older adults. Constant beeping of equipment, lack of space for caregivers to accompany patients, and bright fluorescent lights on all night may increase risk of delirium. Providers are expected to assess patients in mere minutes, but it is difficult if not impossible to assess the complex medical conditions and subtle presentations of older adults under such circumstances. As a result of the mismatch between care delivery in the ED and needs of older adults, older adults often experience poor outcomes as a result of ED visits. These poor outcomes are welldocumented, and include falls, delirium, functional decline, and increased mortality. 4 Trailblazing initiatives over the past couple of decades have highlighted the importance of improving care for older adults in the ED, and we see new care models emerging. In 2014, multiple professional organizationsÀincluding the American College of Emergency Physicians and the Emergency Nurses Association among oth-ersÀcame together to create the Multidisciplinary Geriatric Emergency Department Guidelines. 5 The purpose of these guidelines was to create standardized recommendations to guide the optimization of care of older adults in the ED. The guidelines include recommendations on structure and processes of care, including staffing, care transitions, infrastructure and policies and procedures, among many others. In 2018, the American College of Emergency Physicians began accrediting facilities as geriatric Emergency Departments.

Due to these and other efforts, geriatric Emergency Department interventions and innovations (GEDI's) are becoming more common. 6 The gold standard of these innovations is the standalone geriatric ED unit. These units are modeled upon similar approaches to pediatric and psychiatric ED's and have designated areas designed specifically for the special needs of older adults. Physical spaces incorporate the needs of older adults, including nonskid floors, handrails, lighting that follows diurnal patterns, and pressure-reducing air mattresses. All staff are educated in geriatric principles and specialized geriatrics providers are available for consult. Processes are implemented for screening older adults for dementia, delirium, and other geriatric syndromes.

Nursing has been at the forefront of these efforts to improve care for older adults in the ED across the spectrum of education, practice, and research. The Nurses Improving Care for Healthcare Elders (NICHE) has designed resources for patients and caregivers to help them navigate the ED, 7 while the Emergency Nurses Association has developed a comprehensive course on Geriatric Emergency Nursing Education aimed at training nurses to improve outcomes for older adults in the ED. 8 Another resource is the newly formed Geriatric Emergency Department Collaborative, which focuses on interdisciplinary care of the older adult in the ED (see https://gedcollaborative. com/). A number of research studies have examined nurse-led multidisciplinary GEDI's. For example, a study of a Transitional Care Nurse model, in which an ED nurse was trained to facilitate care transitions for older adults, reduced subsequent inpatient admissions by 5%À16%. 9 However, other studies have shown mixed results on the impacts of nurse-led interventions, demonstrating there is still more work to do to understand the best models of care. 10 As frontline providers, nurses offer a unique perspective on caring for older adults in the ED. Nurses are the most numerous health professionals in the ED and often the first and most frequent point of contact for patients. Given their vantage point, nurses bring critical ideas for improving care for older adults in the ED, as well as help us understand when interventions fail. Bedside nurses have emphasized the need for interdisciplinary, evidence-based protocols to help prevent, detect, and manage geriatric syndromes. 11 Put simply, there is no way to improve care for older adults in the ED without the engagement of nursing.

How else can nurses take an active role in improving care for older adults in the ED? While there may not be resources to develop a standalone Geriatric ED in their institutions, nurses can advocate for smaller scale interventions that can still have a big impact. For example, institutions could implement a geriatric practitioner model, where a clinician geriatric expert, such as a geriatric nurse and/or advanced practice nurse, are available for consultations for individual patients, as well as responsible for leading education efforts on the unit. Moreover, nurse educators should ensure that they are teaching principles of geriatric care to all of their staff and students.

Nurses can also help push for more financial investment in research, education, and training specific to geriatric nursing through policy advocacy. While the National Cancer Institute receives $600 billion in appropriations each year, the National Institute of Nursing Research receives a mere $300 million. Funding for the NINR should be increased and efforts should focus on testing and implementing nurse-led multidisciplinary GEDI's. Moreover, fewer than 1% of registered nurses specialize in geriatrics, and this number is declining. We need more funding to increase the number of registered and advanced practice nurses pursuing a focus on geriatrics, but it is also critical that geriatric curriculum is infused into the training of all nurses. 12 An older adult with an active COVID-19 infection should not also have to worry about falls and delirium when presenting to the ED. It is past time to increase efforts to improve care for older adults in the ED. As the junction between the outpatient and inpatient settings, there is tremendous opportunity to improve care older adults receive not only in the ED itself, but across the spectrum of care. With increased recognition of the importance of improving care for older adults in the ED and the emergence of GEDI's, we have made some strides. But there is still a long way to go. Nursing, in particular geriatric nursing, has been and needs to continue to be at the forefront of these efforts, and funding efforts should reflect the importance of geriatric nursing to the care of older adults in the ED.

Dr. Hunt is supported through the National Institutes of Health (KL2 TR001870); UCSF Pepper Center (P30 AG04428); a National Palliative Care Research Center Career Development Award; and the Global Brain Health Institute/Atlantic Philanthropies.

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Geriatric emergency department innovations: transitional care nurses and hospital use

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Care of the older adult in the emergency department: nurses views of the pressing issues

Who cares for older adults? Workforce implications of an aging society