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[PREPARING FOR THE GERIATRIC TSUNAMI – AN EMERGENCY DEPARTMENT PARADIGM SHIFT - James Ducharme MD CM, FRCP]
become the emergency department. In countries lacking
strong Primary Care services, the impact on the ED risks
being even more dramatic.
No matter what health care system is developed, the emer-
gency department will receive increasing numbers of the ill
and injured elderly. Just as the ED has adapted to the para-
digms listed above, so too must it adapt to this paradigm
of an aging population. As it stands, most emergency physi-
cians are probably ill prepared to deal with the complexities
of geriatric medicine, with inadequate training objectives
during residency training (5). Medical care cannot be easily
separated from the physical and social care needs of the
elderly, so that the ED will have to build an infrastructure
than can address all facets of care in a timely fashion. If
the health care system does not develop simultaneously a
support system external to the hospital, the ED risks being
overwhelmed and crowded to dysfunctional levels solely by
the
non-medical
demands of the elderly. Care must be taken
to create a geriatric friendly ED that:
1) Achieves buy in from all involved stakeholders
2) Addresses the needs of the emergency geriatric patient
without encouraging excessive referrals or prolonged stays
in the department
3) Allows normal flow and functionality for other age groups
– reserving space for one age group without increasing the
ED footprint could severely limit the space for other age
groups in most EDs.
4) Meshes with a hospital and system equally adapted for
geriatric patients, with an inpatient acute rehabilitation ward
and processes for rapid transition back into the community
for respite care, alternative care and long term care facilities.
For almost every country except the United States, the
concept of a
geriatric emergency department (GED)
will
not be a marketing strategy aimed at increasing hospital
and ED revenues. Rather, a dedicated program with specific
needs will further cut into a strained hospital budget. Finan-
cial constraints will be in play for everyone; many national
health care administrators will identify that placing all the
geriatric ‘eggs’ in one basket (the ED) for medical investi-
gation, initiation of transition into social support or a long
term care facility and localization of a multi-disciplinary
team will create a cost effective and simple solution. In
such a set-up, Primary Care providers will often have more
limited access to such services, risking the default of their
efforts to the ED unless the new system accounts for rapid
access from the community providers.
Several United States medical organizations have collaborated
to produce a guideline for a geriatric emergency department
(6). In addition to infrastructure recommendations, it also
provides direction for screening, medication management,
assessment of falls, delirium & dementia and palliative care.
Key to such a document’s success is standardization of care
through effective knowledge translation, as well as defining
clearly the roles of the GED, including the ‘negatives’: who does
not
require hospital admission, who should not be sent to the
GED from the community, and duration of GED stay. In line with
the notion of cost effective prevention, screening to predict
future adverse outcomes becomes a critical aspect of the GED
role; existing strategies unfortunately still fall short (7).
When one considers the increasing needs of the elderly
outside of
the hospital, it becomes evident what the GED
will have to be able to address:
1) Deconditioning after injury or illness
2) Declining cognitive function
3) Loss of functional independence
4) Adapting home environments to decreased functionality
and impairments
5) Home care support for meals, bathing, medical needs
(wound care, peritoneal dialysis, etc.)
The GED will have to have direct access to, or have working
in the department, a comprehensive team including
physiotherapy, occupational therapy, social worker, a geriatric
nurse, a wound care nurse and home care nurses. Nurses and
the pharmacist within the unit should have specific exper-
tise with geriatric patients. To continue to function well, it
will have to be able to transfer patients directly to respite or
rehabilitation beds outside the hospital. It will also have to be
able to ensure home care within 12-24 hours of discharge:
in addition to acute medical care such as IV medications and
wound care rehabilitation, meal support, assessment of fall
risk etc. will also have to be available in a timely fashion.
The GED cannot be built in isolation, but within the context
of a system established for this paradigm. That has not yet
happened systematically in Canada, placing an inordinate
burden on the ED team. The elderly present 24 hours a day
to the ED; the multi-disciplinary team should be available 7
days a week, 16 hours a day at a minimum, or the system will
risk being overwhelmed with patients waiting to be seen by
the various members of the team.
The physical setup of the GED will have to include beds
adapt to the physical limitations of the elderly, nearby
adapted bathroom facilities, large clocks easily read from
any bed with time and date, a dedicated area for physio-
therapy to assess patient function (not a hallway), and areas
for meeting with multiple family members. While specifi-
cally of benefit to the elderly, many of these requirements
will be of value to patients and families of almost every age
group.