Evidence-Based Medicine
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by Bob Fitzgerald, MD

It’s the middle of a typical hellacious Saturday night shift and your next patient is a 90-year-old gentleman who lives at home with his wife and who fell walking to the bathroom. He has a large scalp laceration, is pleasantly demented, but is becoming more agitated and combative. His wife is “too frail” to come to the ED and the only history you have is a bag with 14 pill bottles in it. Your social worker is long gone, you’re two hours behind on seeing patients, and you look at the full tracking screen and note three more octogenarians with the same chief complaint: weak and dizzy. You soldier on . . .

I work in Sun City, Arizona, where over half my patients are over 70 years. I tell colleagues around the country that I work in “The ED of the Future.” Every shift, I see firsthand the complexities and difficulties of this patient population. Quite frankly, I could not get through a shift without the support of our ED social worker, clinical pharmacist and MLP’s and the outpatient care options available here.

THE AGING OF THE POPULATION
78 million baby boomers will become eligible for Medicare starting in 2011 at the rate of 10,000/day. This will undoubtedly create a huge increase in healthcare demand. ED’s will play a pivotal role because they are the critical interface between outpatient services and inpatient care and have a significant effect on resource utilization.

For emergency medicine to be prepared for this essential role, we must:
(1) Recognize the magnitude of the impact of geriatrics on our practices;
(2) Understand the medical and financial imperatives to change our paradigm of care;
(3) Create a new model of geriatric ED practice.

IMPACT OF GERIATRICS
In 2000, 38 million Americans were over age 65. By 2030, this figure will grow to 75 million elderly, with the fastest growth in the “oldest old” (>75 years), who will require more services just when the numbers of doctors choosing primary care are falling dramatically.

Managing the elderly in the outpatient setting is problematic at best because of the limitations imposed by cognition, mobility, transportation, and the limited availability of subspecialists. Hospital-based EDs, with their “one-stop shopping,” become an attractive alternative, especially with abrupt changes in clinical status. And, of course, on weekends, holidays and after hours, we are always the venue of choice. Geriatric ED utilization rates have already been rising – from 12% to 16% of all ED visits from 1993-2003 – a trend which will undoubtedly increase in the future. Conservative estimates see geriatrics as 25% of all ED visits by 2025, and many believe that 30% is closer to the truth.

CHANGING THE PARADIGM OF CARE
The present model of ED care is designed to best serve acutely ill and injured patients requiring rapid interventions and treatments. This paradigm is ill-suited for the typical geriatric patient who has multiple co-morbidities and medications and presents with enigmatic complaints that evolve over a long period of time. There are both medical and financial imperatives to change our model.

Compared with younger severity-matched cohorts, geriatric patients have poorer clinical outcomes. A lack of geriatric-specific training and clinical exposure coupled with limited research and evidence-based protocols compounded by atypical presentations often lead to delayed/missed diagnoses (AMI, sepsis, appendicitis), unsuspected diagnoses (delirium, depression, elder abuse, polypharmacy), undertreatment (PCI in AMI, inadequate pain management) and overtreatment (frequent bladder catheterization, overuse of sedative/hypnotics).

Most importantly, geriatric patients demand the one thing we are least able to give: TIME. Especially in a busy ED, our present model limits our ability to accurately understand their medical needs because of the pressures to move patients through the system quickly. As one nurse colleague succinctly summarized, “It takes me 20 minutes just to undress them, get an accurate med list and a clean UA.”

The financial imperatives of tightening Medicare reimbursements will dramatically affect ED practices in the near future. Falling revenues will further strain physician-patient ratios and limit availability of subspecialists to support our practices. But the financial impact will extend far beyond the walls of the ED. Because we are the biggest Medicare admitters (57% nationally), the consequences of our clinical decisions go directly to the hospital’s bottom line. Twenty-three of the 25 most common DRG’s have a negative cost recovery, and most studies indicate hospitals lose between 15-20% on each Medicare patient. Unfortunately, the future doesn’t look much brighter. The Budget Reconciliation Act of 2005 mandates total reimbursement limits regardless of demand. Following these guidelines, the 2009 Federal Budget proposal includes a $15 billion reduction in hospital payments over the next five years. President Obama has publicly stated he will make controlling Medicare costs a “central part” of his deficit reduction plan. And the scope and related demands and costs of a possible new national healthcare system, also an Obama priority, remain a complete unknown.

What will be the effect of these financial realities on our geriatric EM practices? There will be increasing pressures for EDs to act as more stringent gatekeepers for Medicare admissions – especially for those with vague medical complaints. The era of low thresholds for admissions will be a thing of the past. EDs will be expected to do more extensive evaluations, observe patients longer, seek more consultations, and explore outpatient alternatives. In this new gatekeeper role, EDs will become de facto observation units to prevent avoidable hospitalizations. Clinically, I feel this is the right approach. Hospitals can be dangerous places for elderly patients who do not absolutely need inpatient care.

A NEW MODEL FOR ED GERIATRIC CARE
There has to be a man-on-the-moon-this-decade urgency to change the paradigm of geriatric emergency medicine that will require commitment and a great deal of focused effort. We must begin the process by defining the key elements of this new model: infrastructure, integration and an implementation strategy.

Infrastructure: The foundation of improvement rests on the dual pillars of education and clinical research. Until recently, there has been a deficit of geriatric-specific training in EM residencies. Fortunately, both ACEP and SAEM have been developing elements of a core curriculum to address this. Once developed, this core of knowledge needs to be disseminated to front line caregivers in much the same way as with pediatric and trauma standards of care. The second pillar of clinical research should include special emphasis on risk stratification, prevention, disposition, and outcomes and should include the community hospital setting. These two pillars should lead to at least three useful tools:
(1) Clinical protocols for acute ED care;
(2) Clinical pathways for more definitive treatment in both inpatient and outpatient settings; and
(3) Quality measures to assess our clinical practice.

Integration: Emergency physicians will need to use these pathways to guide the patient seamlessly through the system to the most appropriate clinical setting which may include a period of observation before disposition. On the inpatient side, the ED course should complement and expedite hospital care to minimize length of stay and maximize outcomes. On the outpatient side, the ED should be closely linked with all available resources pertinent to discharge, including the ability to communicate data on our care to those responsible for follow-up.

Implementation: Changes need to be made in ED staffing and design to operationalize this focused geriatric care. Since these patients demand more time and attention than the typical doc-nurse-tech model can give, a geriatric team concept needs to be developed that would ideally include a social worker/case manager and a midlevel provider, supplemented by a clinical pharmacist, OT/PT, pastoral care, etc., as needed. As is the case today, acute medical issues would be addressed by the core ED staff. The rest of the team will be needed to gather all relevant clinical information, address important but non-acute medical issues, explore all disposition options, and screen for other conditions that may affect outcomes.

New design concepts are needed to support this new model of care beginning with the recognition that previous bed number estimates should be revised to reflect increasing lengths of stay. Adjacencies for diagnostic studies and treatments need to be incorporated into overall hospital design as well as accommodations for increasing numbers of caregivers and consultants. Observation areas, either in the hospital or the ED, will be necessary to allow appropriate evaluations. Making our practices more geriatric friendly means addressing the bright, loud, chaotic, cold, uncomfortable environments seen in most departments today by providing quiet, private rooms with softer lighting schemes and pressure-resistant mattresses in close proximity to caregivers with adequate space for in-room visitors and family.

In twenty years most EDs will look like Sun City, at least to some extent. We need to be prepared to provide the best geriatric acute care without placing our hospitals in financial jeopardy.

Bob Fitzgerald, MD, has practiced emergency medicine for 33 years, 16 of which were spent as an ED Director. 
 

Comments   

# Director of Emergency Medicine, Medical Specialists LLCJudi Moore 2009-02-26 03:34
This article has successfully outlined what the world of EM will be in the next few years. The author is very insightful, knowledgeable and has a great fund of knowledge in the world not only of Geriatric EM practices but EM practices overall. It contains practical, appropriate assessments. Thank you very much for this article. I am passing it along to all EM Directors I work with.
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# Emergency Medicine at a CrossroadsChris Carpenter 2009-02-26 13:34
Dr. Fitzgerald's article highlights the predominant challenge facing 21st Century Emergency Medicine. The baby-boomers represent a demographic tidal wave that has never been seen before. Unfortunately, they begin to arrive at a time when Medicare faces insolvency by 2015 and the economy struggles to recover while facing a $1.7 trillion deficit. Furthermore, a retiring physician workforce will further strain already insufficient primary care and geriatric specialist availability. Here's the good news: innovative physicians, nurses, and ancillary emergency health care providers are actively and increasingly providing viable solutions to the geriatric emergency care challenge including building older adult friendly EDs, incorporating geriatric competencies in education and quality indicators into practice standards. I hope EP Monthly readers will use this forum to identify creative solutions and innovative individuals. Stay tuned for the June 2009 issue of EP Monthly that will revolve around the theme "Aging America" with multiple stories about Emergency Medicine's response to the baby-boomer demographic tsunami we are all facing. Chris Carpenter, MD, MSc
EP Monthly Chief Clinical Editor
Reply
# Geriatric cultural and linguistic competency educational opportunityUla Hwang 2009-02-26 15:30
Dr. Fitzgerald's article is a wonderful "call to arms" about the urgent need for a paradigm shift in how the ED will have to model patient care for geriatric patients. Not only will infrastructure, integration, and implementation be necessary, but a general understanding of how to communicate with older adults and their caregivers.

A wonderful opportunity for those in the NY and Mid-Atlantic region is availalble. The Consortium of New York Geriatric Education Centers and Mount Sinai School of Medicine present the CNYGEC Faculty Development Conference: Interdisciplina ry Geriatric and Cultural and Linguistic Competency on March 9th, Match 16th, and April 13th 2009. This course will be held at the James J. Peters VAMC at 130 W. Kingsbridge Road Bronx, NY.



This conference is targeted to interdisciplina ry academic and clinical faculty, fellows and residents. The course covers geriatric content, health literacy, cultural competence, healthcare disparities, patient-centere d care, and complementary and alternative medicines. Sessions are taught through demonstrations, self-study, small- and large-group sessions. CME credits are awarded.

For information, please contact Jennifer Griffith at Jennifer.Griffith@mssm.edu.

Th posted comment is not an attempt to advertise for the organizations holding this conference, but instead to highlight that opportunities exist for EM physicians to improve their ability and comfort level in providing care for older adults.
Reply
# Education and Research Needed to Solve the CrisisTeresita Hogan 2009-02-26 17:22
Practice change is not easy. We have to first learn and understand the right thing to do, then demonstrate to others that it works. Only with these two factors in hand will doctors and hospitals change operations and protocols.
Emergency Medicine Residencies will soon formally implement geriatric competencies into the curricula.
On Tuesday, February 17, 2009, President Obama signed the American Recovery & Reinvestment Act giving the National Institutes of Health (NIH) an unpresidented $10.4 billion for use over 2009 and 2010. We need to lobby the NIH and especially the National Institute of Aging for research into emergency care of elders. If used correctly, these two factors will go a long way to resolving the crisis.

Reply
# NY Times StoryChris Carpenter 2009-04-02 14:24
Timely NEJM-based NY Times story today http://www.nytimes.com/2009/04/02/health/02hospital.html?_r=2&ref=health

discussing Medicare patient 1-month re-admission rates following hospital discharge (1 in 5)with 1 in 3 re-admitted at 90-days. Look at your hospital's census today and project the numbers 10-years forward when octogenarians have nearly doubled in number and 20% are being re-admitted every month. How will your hospital respond? Has your institutions began their planning process for these increasing numbers? Creative solutions like the Hospital-at-Hom e (Bruce Leff @ Hopkins) are desperately needed.
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