E. Chong1,2, T. Ong3, W.S. Lim1,2
1. Department of Geriatric Medicine, Tan Tock Seng Hospital, Singapore; 2. Institute of Geriatrics and Active Ageing, Tan Tock Seng Hospital, Singapore; 3. Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia.
Corresponding Author: Edward Chong, Tan Tock Seng Hospital, Singapore, dr.edwardchong@gmail.com
J Frailty Aging 2023;12(4)254-257
Published online September 25, 2023, http://dx.doi.org/10.14283/jfa.2023.42
Emergency Departments (ED) across the globe are progressively challenged to provide high value geriatric care to acutely ill and frail older persons. This is fueled by the rapid and disproportionate rise in older persons attending EDs, which adds significant pressure to healthcare systems worldwide (1, 2). Older persons not only bring along considerable acute illnesses and comorbidities, but challenges even the most seasoned ED clinicians with their constellation of physical, psychological, functional, and social needs, which may not be readily apparent (3). The multidimensionality of care needs is often described by a single word – frailty – a well-known syndrome defined as a state of reduced strength and physiological malfunctioning that increases a person’s susceptibility to increased dependency, vulnerability, and even death (4-7). Therefore, it is often the complexity of care exhibited by these vulnerable individuals that demand our full attention amid significant time-constraints with limited manpower at the ED (8, 9). This not only impacts on patients’ health outcomes but exposes ED professionals to burnout and low job satisfaction (10, 11).
Three predominant factors are paramount in significantly influencing hospitalization outcomes among older persons, namely acuity-of-illness at presentation, premorbid frailty status, and the incidence of hazards of hospitalizations including nosocomial infections, iatrogenic complications, and functional decline (12, 13). While not much can be done to modify the former two factors once patients present to the ED, a great window of opportunity exists to mitigate the latter with possibility of admission avoidance through the prompt delivery of effective geriatric care right at the front-door of acute hospitals. Given that EDs stand as a portal to multiple care settings (i.e., acute, subacute, short-stay, intermediate, ambulatory, and palliative care), it is imperative to ensure the right patient gets the right care, and is linked-up to the right services (14).
The quadruple aim
Against this backdrop, EDs must work towards developing well-crafted strategies to embrace the critical megatrend of an aging population. To this end, we propose the adoption of the Quadruple Aim framework to promote the development and delivery of high value healthcare systems (15, 16) (Figure 1). It comprises four key objectives: improving patient health outcomes, reducing cost, improving patient experience, and improving healthcare team experience. Each objective is complementary to each other and is correlated with organizational efficiency, which ultimately enhances productivity (16). Hence, bearing the Quadruple Aim framework in mind, and recognizing that traditional ED care models can no longer adequately meet the needs of older persons, the leadership within healthcare organizations must support their EDs in every effort to redesign current care systems and practices in order to address the mismatch between existing care delivery and evidence-based best practices for caring for older persons.
Models of care for a frailty-ready ed
Several models of care for a frailty-ready ED already exist and can be divided into two broad categories: 1) environmental improvements for a senior-friendly ED that incorporates Geriatric Emergency Department (GED) care principles (17-29), and 2) geriatrics practitioner or champion care model (17, 25). The primordial model is the concept of a distinct Older People’s Emergency Department (OPED), which has been well established in the US, Italy, and England (17-20). The first OPED in England was established in 2017 with staff consisting of a multidisciplinary team of advanced clinical practitioners, community access teams, nurses, geriatricians, and junior doctors. It focuses on delivering emergency care to patients aged 80 years and above. While a recent retrospective cohort study failed to show that OPED could significantly reduce the likelihood of hospitalization, it did demonstrate shorter wait for clinical assessment and reduction in time spent in the ED (20). As this concept remains at its infancy, future work is still needed to evaluate short- and long-term outcomes for patients under OPED care.
If constructing an OPED is not a viable solution, then carving out a dedicated space within the ED can be considered. Numerous hospitals in the US have established GED units (17, 21). These units are designed with structural enhancements to provide a senior-friendly environment for older patients and is often staffed with a multidisciplinary team of geriatric experts comprising geriatricians, nurses, palliative care specialists, social workers, case managers, therapists, and pharmacists. Due to limited bed capacity, screening assessments are essential to identify patients who will benefit most from the multipronged evidence-based protocols delivered at these units. The GED care model has been demonstrated to increase the likelihood of discharge, reduce hospital admissions and readmissions, shorten lengths of stay (LOS) at ED and hospital settings, decrease hospital costs, and reduce mortality risks (21-24).
Next, EDs can consider establishing geriatric-focused observation units. An increasing number of EDs have now established observation units, which are primarily designed to admit patients with an anticipated LOS of 24-48 hours (26-28). Older patients admitted to these units typically include those with presentations of falls with minor injuries, mild infections, minor trauma or road traffic accidents, and non-traumatic musculoskeletal pain (29). These units often have senior-friendly structural improvements and are developed with geriatric-focused care protocols including early administration of the CGA, which can be delivered by ED physicians and nurses trained in geriatric care. It has been successful in decreasing admissions, readmissions, and functional decline among older adults discharged from the unit (26-28).
If no dedicated space is available, EDs can consider adopting the geriatrics practitioner care model (17, 25). Geriatric-focused care approaches can be developed, which may include environmental improvements along with well-crafted evidence-based geriatric protocols (from assessment to discharge and care transitions). The model can be delivered by a multidisciplinary team of geriatric experts who can be permanently based at the ED or be activated to come down when required. The Emergency Department Interventions for Frailty (EDIFY) and the Older People Assessment and Liaison (OPAL) programs are examples of this care model (29-32). EDIFY was established in a busy ED of a 1700-bed tertiary acute hospital in Singapore with the primary aim of reducing potentially avoidable acute admissions among older patients (30). The program also delivers early CGA and frailty education to suitable older patients admitted to the ED observation unit (29). It comprises of a team of geriatric experts including a geriatrician, advanced practice nurse (APN), pharmacist and physiotherapist. The program has been shown to reduce acute admissions, attenuating frailty progression, and is potentially cost-effective (30, 31). Additionally, the program was found to improve functional outcomes and reduce ED re-attendances while attenuating sarcopenia progression by administration of early CGA among older adults (29).
If there are limited provisions for geriatrics practitioners, a geriatric champion who is normally a physician or nurse with geriatric care expertise can be appointed to lead initiatives and care coordination pathways (17, 21). The Geriatric Emergency Department Intervention (GEDI) model is an example of a nurse-led, physician-championed intervention that has successfully translated into new ED sites in Australia (25).
How can the quadruple aim be achieved?
With a firm evidence base as the springboard, the next frontier would be dissemination and context-congruent implementation of the frailty-ready ED models of care (33). In this regard, how can the Quadruple Aim help ED systems achieve high-value frailty-ready care? Figure 1 provides examples of focus areas that may be prioritized for development in order to achieve the Quadruple Aim at the ED. Firstly, improving patient health outcomes at the ED may be achieved by developing systems and processes that can effectively deliver one of the aforementioned models of care, which should also include timely assessment using a risk stratification tool that integrates a rapid frailty assessment, early geriatric assessment incorporating CGA principles, a process for identifying cases who have the potential for acute admission avoidance, and a process for enhanced care integration back to the community (17, 34, 35). Secondly, reducing healthcare cost may be achieved by prioritizing the delivery of cost-effective and sustainable care, and by decreasing ED utilization through pre-hospital care initiatives (36), reduced ED re-visits and hospitalizations, and reduced unnecessary investigations. It is also equally, if not more important, that hospitals work collaboratively with primary healthcare providers to build up capacity and provide support in assessing and managing frail older persons, without which the overwhelming number of patients accessing the ED may remain unavoidable (37, 38). Thirdly, improving patient experience may be achieved through the development of a senior-friendly ED, delivering personalized care especially among groups with special needs, and improving patient journey by reducing waiting time, improving communication, and having a friendly and caring ED workforce who have a deeper appreciation of aging physiology and geriatric syndromes. Lastly, improving staff experience may be achieved through collective leadership that promotes a supportive and nurturing work culture, with an emphasis on developing a strong healthcare workforce through staff development and training that incorporates principles of geriatric medicine, fostering a culture of quality improvement, and enhancing staff wellbeing (15, 16, 39, 40).
Conclusion
There is an urgent need for EDs to sense the exigency to be frailty-ready by redesigning their delivery of care for older adults to prioritize frailty-centric interventions and consider the needs of the population they serve; harness the expertise and ensure the wellbeing of their front-door healthcare workers; and optimize the resources which are readily accessible to them. To achieve the Quadruple Aim of high-value frailty-care at the ED, collective leadership is essential and should be guided by the four tenets that inspires innovation and creativity to promote understanding of practice variation and benchmarking of best practices; critically appraises latest evidence to facilitate timely translation of evidence-based best practices; redesigns care delivery models in a sustainable and cost-effective way; and increases emphasis on healthcare staff support and wellbeing (41).
Conflicts of Interest: None to declare.
References
1. Gomes, J.C.P., Dias, R.D., de Barros, J.V. et al. The growing impact of older patients in the emergency department: a 5-year retrospective analysis in Brazil. BMC Emerg Med 20, 47 (2020). doi:10.1186/s12873-020-00341-y.
2. Magidson PD, Carpenter CR. Trends in Geriatric Emergency Medicine. Emerg Med Clin North Am. 2021;39(2):243-255. doi:10.1016/j.emc.2020.12.004.
3. Simon NR, Jauslin AS, Bingisser R, Nickel CH. Emergency presentations of older patients living with frailty: Presenting symptoms compared with non-frail patients. Am J Emerg Med. 2022;59:111-117. doi:10.1016/j.ajem.2022.06.046.
4. Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013;14(6):392-397. doi:10.1016/j.jamda.2013.03.022.
5. Cesari M. Frailty and Aging. J Frailty Aging. 2012;1(1):3-6. doi:10.14283/jfa.2012.1.
6. Ferri-Guerra J, Aparicio-Ugarriza R, Salguero D, et al. The Association of Frailty with Hospitalizations and Mortality among Community Dwelling Older Adults with Diabetes. J Frailty Aging. 2020;9(2):94-100. doi:10.14283/jfa.2019.31.
7. Aarts S, Patel KV, Garcia ME, et al. Co-Presence of Multimorbidity and Disability with Frailty: An Examination of Heterogeneity in the Frail Older Population. J Frailty Aging. 2015;4(3):131-138. doi:10.14283/jfa.2015.45
8. Ukkonen M, Jämsen E, Zeitlin R, Pauniaho SL. Emergency department visits in older patients: a population-based survey. BMC Emerg Med. 2019;19(1):20. Published 2019 Feb 27. doi:10.1186/s12873-019-0236-3.
9. Hwang U, Morrison RS. The geriatric emergency department. J Am Geriatr Soc. 2007;55(11):1873-1876. doi:10.1111/j.1532-5415.2007.01400.x.
10. Moukarzel A, Michelet P, Durand AC, et al. Burnout Syndrome among Emergency Department Staff: Prevalence and Associated Factors. Biomed Res Int. 2019;2019:6462472. Published 2019 Jan 21. doi:10.1155/2019/6462472.
11. Kubicek B, Korunka C, Ulferts H. Acceleration in the care of older adults: new demands as predictors of employee burnout and engagement. J Adv Nurs. 2013;69(7):1525-1538. doi:10.1111/jan.12011.
12. Pulok MH, Theou O, van der Valk AM, Rockwood K. The role of illness acuity on the association between frailty and mortality in emergency department patients referred to internal medicine. Age Ageing. 2020;49(6):1071-1079. doi:10.1093/ageing/afaa089
13. Schimmel EM. The hazards of hospitalization. 1964. Qual Saf Health Care. 2003;12(1):58-64. doi:10.1136/qhc.12.1.58
14. Ranger CA, Bothwell S. Making sure the right patient gets the right care. Qual Saf Health Care. 2004;13(5):329. doi:10.1136/qhc.13.5.329.
15. Sikka R, Morath JM, Leape L. The Quadruple Aim: care, health, cost and meaning in work. BMJ Qual Saf. 2015;24(10):608-610. doi:10.1136/bmjqs-2015-004160.
16. Arnetz BB, Goetz CM, Arnetz JE, et al. Enhancing healthcare efficiency to achieve the Quadruple Aim: an exploratory study. BMC Res Notes. 2020;13(1):362. Published 2020 Jul 31. doi:10.1186/s13104-020-05199-8.
17. American College of Emergency Physicians; American Geriatrics Society; Emergency Nurses Association; Society for Academic Emergency Medicine; Geriatric Emergency Department Guidelines Task Force. Geriatric emergency department guidelines. Ann Emerg Med. 2014;63(5):e7-e25. doi:10.1016/j.annemergmed.2014.02.008.
18. Keyes DC, Singal B, Kropf CW, Fisk A. Impact of a new senior emergency department on emergency department recidivism, rate of hospital admission, and hospital length of stay. Ann Emerg Med. 2014;63(5):517-524. doi:10.1016/j.annemergmed.2013.10.033.
19. Salvi F, Morichi V, Grilli A, et al. A geriatric emergency service for acutely ill elderly patients: pattern of use and comparison with a conventional emergency department in Italy. J Am Geriatr Soc. 2008;56(11):2131-2138. doi:10.1111/j.1532-5415.2008.01991.x.
20. Meechan C, Navaneetharaja N, Bailey S, et al. EVALUATION OF THE FIRST OLDER PEOPLE’S EMERGENCY DEPARTMENT IN ENGLAND – A RETROSPECTIVE COHORT STUDY [published online ahead of print, 2023 Apr 14]. J Emerg Med. 2023;S0736-4679(23)00227-5. doi:10.1016/j.jemermed.2023.04.003.
21. Southerland LT, Lo AX, Biese K, et al. Concepts in Practice: Geriatric Emergency Departments. Ann Emerg Med. 2020;75(2):162-170. doi:10.1016/j.annemergmed.2019.08.430.
22. Hwang U, Dresden SM, Rosenberg MS, et al. Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use. J Am Geriatr Soc. 2018;66(3):459-466. doi:10.1111/jgs.15235.
23. Shadyab AH, Castillo EM, Chan TC, Tolia VM. Developing and Implementing a Geriatric Emergency Department (GED): Overview and Characteristics of GED Visits. J Emerg Med. 2021;61(2):131-139. doi:10.1016/j.jemermed.2021.02.036.
24. Dresden SM, Hwang U, Garrido MM, et al. Geriatric Emergency Department Innovations: The Impact of Transitional Care Nurses on 30-day Readmissions for Older Adults. Acad Emerg Med. 2020;27(1):43-53. doi:10.1111/acem.13880.
25. Marsden E, Craswell A, Taylor A, Barnett A, Wong PK, Wallis M. Translation of the geriatric emergency department intervention into other emergency departments: a post implementation evaluation of outcomes for older adults. BMC Geriatr. 2022;22(1):290. Published 2022 Apr 7. doi:10.1186/s12877-022-02999-4.
26. Pareja-Sierra T, Hornillos-Calvo M, Rodríguez-Solís J, et al. Implementation of an emergency department observation unit for elderly adults in a university-affiliated hospital in Spain: a 6-year analysis of data. J Am Geriatr Soc. 2013;61(9):1621-1622. doi:10.1111/jgs.12433.
27. Southerland LT, Vargas AJ, Nagaraj L, Gure TR, Caterino JM. An Emergency Department Observation Unit Is a Feasible Setting for Multidisciplinary Geriatric Assessments in Compliance With the Geriatric Emergency Department Guidelines. Acad Emerg Med. 2018;25(1):76-82. doi:10.1111/acem.13328.
28. Foo CL, Siu VW, Tan TL, Ding YY, Seow E. Geriatric assessment and intervention in an emergency department observation unit reduced re-attendance and hospitalisation rates. Australas J Ageing. 2012;31(1):40-46. doi:10.1111/j.1741-6612.2010.00499.x.
29. Chong E, Zhu B, Ng SHX, et al. Emergency department interventions for frailty (EDIFY): improving functional outcomes in older persons at the emergency department through a multicomponent frailty intervention. Age Ageing. 2022;51(2):afab251. doi:10.1093/ageing/afab251.
30. Chong E, Zhu B, Tan H, et al. Emergency Department Interventions for Frailty (EDIFY): Front-Door Geriatric Care Can Reduce Acute Admissions. J Am Med Dir Assoc. 2021;22(4):923-928.e5. doi:10.1016/j.jamda.2021.01.083
31. Pereira, M.J., Chong, E., Molina, J.A.D. et al. Evaluating Quality-of-Life, Length of Stay and Cost-Effectiveness of a Front-Door Geriatrics Program: An Exploratory Proof-of-Concept Study. J Frailty Aging (2022). https://doi.org/10.14283/jfa.2022.40
32. Keelan R, Briggs S, Wentworth L. Comprehensive geriatric assessment in emergency Department by OPAL (Older People Assessment and Liaison) can prevent admissions. Future Hosp J. 2016;3(Suppl 2):s26. doi:10.7861/futurehosp.3-2s-s26.
33. Mooijaart SP, Carpenter CR, Conroy SP. Geriatric emergency medicine-a model for frailty friendly healthcare. Age Ageing. 2022;51(3):afab280. doi:10.1093/ageing/afab280.
34. Lucke JA, Mooijaart SP, Heeren P, et al. Providing care for older adults in the Emergency Department: expert clinical recommendations from the European Task Force on Geriatric Emergency Medicine. Eur Geriatr Med. 2022;13(2):309-317. doi:10.1007/s41999-021-00578-1.
35. Sloane PD. The Geriatric-Focused Emergency Department: Opportunities and Challenges. J Am Med Dir Assoc. 2022;23(8):1288-1290. doi:10.1016/j.jamda.2022.06.017.
36. Alshibani A, Banerjee J, Lecky F, Coats TJ, Alharbi M, Conroy S. New Horizons in Understanding Appropriate Prehospital Identification and Trauma Triage for Older Adults. Open Access Emerg Med. 2021;13:117-135. Published 2021 Mar 26. doi:10.2147/OAEM.S297850.
37. Astrone P, Cesari M. Editorial: Integrated Care and Geriatrics: A Call to Renovation from the COVID-19 Pandemic. J Frailty Aging. 2021;10(2):182-183. doi:10.14283/jfa.2020.59.
38. Sinclair A. Frailty and Sarcopaenia Trials in Primary Care – Identifying and Overcoming Key Barriers to Successful Clinician Participation. J Frailty Aging. 2015;4(3):129-130. doi:10.14283/jfa.2015.62.
39. Bhattacharya SB, Jernigan S, Hyatt M, Sabata D, Johnston S, Burkhardt C. Preparing a healthcare workforce for geriatrics care: an Interprofessional team based learning program. BMC Geriatr. 2021;21(1):644. Published 2021 Nov 16. doi:10.1186/s12877-021-02456-8.
40. Evashwick CJ. Building the workforce to care for the aged: Can accreditation contribute?. Front Public Health. 2022;10:1062469. Published 2022 Nov 10. doi:10.3389/fpubh.2022.1062469.
41. Iglesia EGA, Greenhawt M, Shaker MS. Achieving the Quadruple Aim to deliver value-based allergy care in an ever-evolving health care system. Ann Allergy Asthma Immunol. 2020;125(2):126-136. doi:10.1016/j.anai.2020.04.007.
© Serdi 2023