Academic Emergency Medicine on Geriatric EDs

SPECIAL CONTRIBUTION

A Profile of Acute Care in an Aging America:Snowball Sample Identification andCharacterization of United States GeriatricEmergency Departments in 2013Teresita M. Hogan, MD, Tolulope Oyeyemi Olade, and Christopher R. Carpenter, MD, MSc

AbstractBackground: The aging of America poses a challenge to emergency departments (EDs). Studies showthat elderly patients have poor outcomes despite increased testing, prolonged periods of observation,and higher admission rates. In response, emergency medicine (EM) leaders have implemented strategiesfor improved ED elder care, enhancing expertise, equipment, policies, and protocols. One example is thedevelopment of geriatric EDs gaining in popularity nationwide. To the authors’ knowledge, this is thefirst research to systematically identify and qualitatively characterize the existence, locations, and featuresof geriatric EDs across the United States.

Objectives: The primary objective was to determine the number, distribution, and characteristics ofgeriatric EDs in the United States in 2013.

Methods: This was a survey with potential respondents identified via a snowball sampling of knowngeriatric EDs, EM professional organizations’ geriatric interest groups, and a structured search of theInternet using multiple search engines. Sites were contacted by telephone, and those confirming geriatricEDs presence received the survey via e-mail. Category questions included date of opening, location,volumes, staffing, physical plant changes, screening tools, policies, and protocols. Categories werereported based on general interest to those seeking to understand components of a geriatric ED.

Results: Thirty-six hospitals confirmed geriatric ED existence and received surveys. Thirty (83%)responded to the survey and confirmed presence or plans for geriatric EDs: 24 (80%) had existinggeriatric EDs, and six (20%) were planning to open geriatric EDs by 2014. The majority of geriatric EDsare located in the Midwest (46%) and Northeast (30%) regions of the United States. Eighty percent servefrom 5,000 to 20,000 elder patients annually. Seventy percent of geriatric EDs are attached to the mainED, and 66% have from one to 10 geriatric beds. Physical plant changes include modifications to beds(96%), lighting (90%), flooring (83%), visual aids (73%), and sound level (70%). Seventy-seven percenthave staff overlapping with the nongeriatric portion of their ED, and 80% require geriatric staffdidactics. Sixty-seven percent of geriatric EDs report discharge planning for geriatric ED patients, and90% of geriatric EDs had direct follow-up through patient callbacks.

Conclusions: The snowball sample identification of U.S. geriatric EDs resulted in 30 confirmedrespondents. There is significant variation in the components constituting a geriatric ED. The UnitedStates should consider external validation of self-identified geriatric EDs to standardize the quality andtype of care patients can expect from an institution with an identified geriatric ED.

ACADEMIC EMERGENCY MEDICINE 2014; 21:337–346 © 2014 by the Society for Academic EmergencyMedicine

From the Section of Emergency Medicine, Department of Medicine, University of Chicago School of Medicine (TMH), Chicago, IL;the University of Chicago (TOO), Chicago, IL; and the Division of Emergency Medicine, Washington University in St. Louis Schoolof Medicine (CRC), St. Louis, MO.Received August 5, 2013; revision received September 6, 2013; accepted September 7, 2013.Dr. Carpenter, an associate editor for this journal, had no role in the peer review or publication decision for this paper. Theauthors have no relevant financial information or potential conflicts of interest to disclose.Supervising Editor: Lowell Gerson, PhD.Address for correspondence: Christopher R. Carpenter, MD, MS; e-mail: [email protected]. Reprints are not availablefrom the authors.

doi: 10.1111/acem.12332 PII ISSN 1069-6563583 337© 2014 by the Society for Academic Emergency Medicine ISSN 1069-6563 337

Current (and soon to be) older adults pose a sig-nificant challenge to the specialty of emergencymedicine (EM).1–4 Despite a trend favoring

increased testing, prolonged periods of observation,and higher admission rates, studies have shown worseemergency department (ED) outcomes in this popula-tion.5–7 In response to the geriatric demographic imper-ative, leaders from the Society for Academic EmergencyMedicine (SAEM) and the American College of Emer-gency Physicians (ACEP) recommend modifying themodel of emergency health care delivery to better carefor older adults.1,8–10 Strategies for improved ED eldercare range from the education and attitude change ofemergency providers to the redesign of ED physicalplants and departmental operational changes.11–16

One recent and evolving response to the aging demo-graphic imperative is the development of geriatric EDs.The geriatric ED theoretically provides selectedimprovements in patient care through specialized ser-vices and environmental enhancements. The rationale insupport of geriatric EDs includes inadequate EM gradu-ate medical education in essential geriatric principles,17

as well as insufficient recognition of geriatric syn-dromes such as dementia and delirium.18–22 In addition,over the next two decades, the U.S. health care systemwill expend a significant and increasing proportion ofmedical capital on aging adults, so developing fiscallyresponsible alternatives to the status quo will becomeincreasingly urgent.23,24

The impetus to develop geriatric EDs varies.25

Although little empiric evidence exists, some reasonsinclude:

1. Patient benefits such as establishment of more accu-rate diagnoses, improved therapies and health out-comes, better customer service, best practiceprotocols, improved safety, and enhanced satisfac-tion.26

2. Hospital benefits such as marketing to attract higherreimbursement populations; growing a referral basefor higher reimbursing hospital-based programssuch as cardiac, neurologic, and orthopedic care;physical therapy services; otolaryngology; and fallscenters.27 The onus to prevent “never events” or iat-rogenic complications such as urinary tract infectionand decubitus ulcers begins in geriatric EDs or thosecaring for geriatric adults in emergency situations.28

Additional benefits could include optimization ofadmission rates and length of stay and decreasedreadmissions.29 More effective collaboration withnursing homes, skilled nursing facilities, emergencymedical services, home services, and communityresources are goals of geriatric EDs.30 The expecta-tion from cooperation of these institutions is forimproved transitions of care, health care mainte-nance, injury prevention, and improved patient satis-faction.31

3. Staff benefits including effective and efficient prac-tices of care; increased satisfaction; focused educa-tion to enhance competence and clinical skills; andprovision of resources such as equipment, tools, andeffective protocols and policies to facilitate the workprocess.27

Although there are many reasons for a hospital toestablish a geriatric ED, no established criteria yet existto define a geriatric ED. To date, each hospital with ageriatric ED self-designates what defines its geriatricED. Other terms connoting enhanced service to olderadults, including “senior ED,” “geriatric-friendly,” and“elder ED,” are all undefined and not quantified. Cur-rent geriatric EDs range from simple marketing toolswith little substance, to areas containing only isolatedphysical plant changes, to departments where uniquepersonnel with geriatric training offer specializedservices.

Thus far, scant published research exists to differenti-ate ED geriatric service provisions from general EDoperations.32,33 Although experts hypothesize about theessential components of a high-quality geriatric ED,34,35

we provide early research to systematically identify andqualitatively characterize the existence, locations, andfeatures of geriatric EDs across the United States. Thesedescriptive details will be essential in understanding thevariety of services offered and evaluation methods. Ourprimary objective was to determine the number, distri-bution, and characteristics of geriatric EDs.

METHODS

Study Design and PopulationThis study was approved by the University of ChicagoInstitutional Review Board, with exemption frominformed consent requirements. As depicted in Figure 1,from October 2012 through May 2013, the search forexisting geriatric EDs was initiated by using a snowballsample36 of seven known geriatric EDs. Snowball sam-pling is a nonprobability sampling technique in whichidentified study subjects recruit or identify other possiblesubjects from among their acquaintances or from poten-tial subjects known by any means. It is a particularly use-ful sampling method for difficult to identify subjects andhidden populations such as drug dealers or illegal aliens.For our objectives, geriatric researchers and clinicianstend to know other geriatric researchers and clinicians,so snowball sampling serves to identify our subject popu-lation more completely. We coupled snowball samplingwith Google, Bing, and PubMed Internet searches for theterms senior, geriatric, elder, and older adult linked withthe terms emergency department or emergency services.E-mail snowball queries were sent to 17 institutions orindividuals (where identified) generated by these initialidentification strategies. This sample generated 22 possi-ble sites. Multiple sample respondents named the entiremembership of the SAEM Academy of Geriatric EM(n = 80; http://community.saem.org/saem/communities/viewcommunities/groupdetails?CommunityKey=0a948e78-7b61-474f-8f8a-45338fbc5e19) and the ACEP Geriat-ric EM Section (n = 140; http://www.acep.org/Content.aspx?id=25112), as likely sources that could identifypotential geriatric EDs. Snowball identification promptedqueries of the memberships of these two organizationsvia group listserves. Additionally, an in-person groupquery occurred during the 2012 ACEP Scientific Assem-bly Geriatric Section meeting. Through the snowballmechanism, the list of potential geriatric EDs grew to 46

338 Hogan et al. • ACUTE CARE IN AN AGING AMERICA

hospitals. We contacted these sites or individuals by tele-phone to confirm geriatric ED existence and to identify ateach a correspondent knowledgeable in the specifics ofthat geriatric ED’s operations. Four hospitals stated thatthey did not operate geriatric EDs and were removedfrom the sample. No ED or administrative personnel forgeriatric ED confirmation or sampling could be identifiedin six hospitals.

Survey Content and AdministrationThe methodology of survey-based research has beendescribed recently.37 When possible, previously validatedsurvey instruments are preferable,38 but for our objec-tives, no such instrument exists. Therefore, our surveyinstrument was developed by a detailed review of exist-ing research focused on ED interventions to improvegeriatric adult emergency care,5,6,13,15,20,25,26,32,34,35,39–46

as well as discussions with a multidisciplinary collabora-tion of representatives from SAEM, ACEP, the AmericanGeriatrics Society, and the Emergency Nurses Associa-tion. This collaboration continues to develop geriatric EDinfrastructure, personnel, protocol, and educational

guidelines. The members of this collaborative workgrouphelped to generate domains and questions for the survey.The University of Chicago Center for Research Informat-ics Bioinformatics Core (http://cri.uchicago.edu/?page_id=1185) assisted to assess survey ease of use andcomprehensibility, as well as with the qualitative analysisof the survey.

Thirty-six hospitals confirmed geriatric EDs, and eachidentified one correspondent in the geriatric ED leader-ship. Each correspondent received a Research ElectronicData Capture (REDCap, http://www.project-redcap.org/)survey via e-mail. Respondents could win a geriatric EMtextbook as remuneration for survey response. The sur-vey contained a snowball sample question requestingidentification of other geriatric EDs known to that indi-vidual. No additional geriatric EDs were identifiedthrough the survey. Reminder e-mails were sent weeklyfor 3 weeks to those who failed to respond. A researchassistant contacted nonrespondents via telephone.Twenty institutions responded to the survey within the3 weeks. The 16 that did not respond were contacted bytelephone, with 10 subsequently completing the survey.

Figure 1. Snowball sampling and survey distribution. ACEP = American College of Emergency Physicians; GED = geriatric ED;SAEM = Society for Academic Emergency Medicine.

ACADEMIC EMERGENCY MEDICINE • March 2014, Vol. 21, No. 3 • www.aemj.org 339

Three did not respond, and three stated they did notoperate geriatric EDs. The entire survey is available inData Supplement S1 (available as supporting informationin the online version of this paper).

Data AnalysisPrimary data analysis was performed using SPSS Statis-tics version 21 (IBM SPSS, Armonk, NY). We summa-rized survey respondents and nonrespondents using aflow diagram.37,47 Frequency tables were created tocharacterize responses.48 Categories were reportedbased on general interest to those seeking to under-stand components of a geriatric ED or as most applica-ble to hospitals planning future geriatric EDs.Categories include date of opening and location, geriat-ric patient volumes, number of general ED and geriatricED beds, physical plant changes, patient selection, staff-ing qualifications and education, policies and protocols,screening and assessment tools, linkage to communityservices, and referral to clinical programs or services.

RESULTS

We surveyed 36 hospitals as detailed in Figure 1. Thirtyhospitals responded and confirmed geriatric ED exis-tence. Respondents consisted of 43% physicians, 50%

nurses, and 7% administrators. Three other sites didnot have geriatric EDs, and we were unable to establishcontact in another three. The response rate was thus83%. Of the 30 respondents confirming presence of orplans for a geriatric ED, 24 had existing geriatric EDs,and six were planning to open geriatric EDs. The list of30 respondents confirming geriatric EDs is attached asData Supplement S2 (available as supporting informa-tion in the online version of this paper).

The first two geriatric EDs opened in 2008, twoopened in 2009, five in 2010, 10 in 2011, seven in 2012,and three in 2013. At the completion of this survey, oneidentified institution planned to open a geriatric ED in2014. The geographic locales of existing geriatric EDsare displayed in Figure 2.

Seventy-seven percent of geriatric EDs are attachedto the main ED, some with contiguous or multipurposebeds. Sixty-six percent have one to 10 geriatric bedsand 24% have 11 to 20 geriatric beds, while only 10%have more than 20 geriatric beds. The total numbers ofbeds in the general EDs among geriatric ED respondersare: 30% with 10 to 20 general beds, 27% with 21 to 40general beds, and 43% with over 40 general ED beds.The annual volume of 80% of the surveyed geriatricEDs is 5,000 to 20,000 patients, while 10% have annualvolumes of less than 5,000 patients and the remaining

Figure 2. Geriatric ED (GED) locations across the United States.


10% have annual volumes of greater than 20,000patients.

As described in Table 1, physical plant changes arecommon among the geriatric EDs: all but one reportedchanges to their beds or mattresses, while 90%reported making modifications to lighting. Respondentsalso reported enhancements for corridor safety, floor-ing, handrails, and sound levels, as well as use of hear-ing and visual aids.

The majority of geriatric EDs select an age cutoff of65 years and older for placement in the geriatric ED. Inaddition to age, 60% of geriatric EDs use the Emer-gency Severity Index (ESI) score49 for appropriate geri-atric ED placement. Most send patients with ESI Level 1to the main ED for evaluation and stabilization, and40% use the discretion of the triage nurse prior toplacement of patients in the geriatric ED. Seventeenpercent use geriatric-specific screening in the assign-ment of patients to the geriatric ED.

Seventy-seven percent of geriatric EDs have staff thatoverlap with the main ED. Eighty percent report thatthere are special qualifications and/or educationalrequirements for geriatric ED staff. Many provide geri-atric ED staff with special training, such as didacticsfor physicians and the Geriatric Nurse Education(GENE) training course from the Emergency NursesAssociation50 for nursing staff. Nursing staff andadvanced practice registered nurses (APRNs) are mostlikely to be uniquely assigned to the geriatric EDwith no general ED responsibilities. Those sites withspecialized geriatric ED personnel most commonly useAPRNs, geriatric nurse liaisons, case managers, andpalliative care consultants. Physician staffing assign-ments to the geriatric ED are listed in Table 2. In addi-tion to provision and education of staff, it is importantto note that geriatric ED personnel may selectivelyspend time on geriatric-specific tasks such as screeningand assessment, transitions of care, and medicationmanagement.

Most geriatric EDs (87%) reported screening for atleast one of four categories of geriatric syndromes. Themost commonly used screening tools in geriatric EDsare cognitive (77%) and functional status (73%) screens,followed by high-risk screening (63%) and medicationmanagement (60%). The most frequently used cognitive

assessment tools were Confusion Assessment Method,51

Identification of Seniors at Risk,52 mini-cog,53 mini-mental state examination,54 and Triage Risk ScreeningTool.55 The most commonly used screening tool formedication management was reference to the Beers Listof inappropriate medications for elders.56 The mostcommon policies and protocols implemented for geriat-ric ED operations include falls prevention (57%),57 medi-cation assessment (57%),58,59 delirium management(40%),60 Foley catheter use (40%),61 and gait assessment(37%).62,63

Ninety percent of geriatric EDs report that they solicitdirect follow-up through patient callbacks. Targetedinterventions to improve health care outcomes are com-mon: 70% have ED staff arrange coordination of outpa-tient community resource services, while 63%coordinate outpatient hospital services. Pharmacologyreview is used by 73% to prevent adverse drug reac-tions, 67% report discharge planning for ED elders, and60% report communication with the patient’s primarycare physician.

Many geriatric EDs reported that they providepatients with extensive post-ED resources. Ninety-threepercent provide linkage to community services, such ashome aids (80%), home equipment (73%), and physicaltherapy (70%). All geriatric EDs also reported postdis-charge referral to at least one of the clinical serviceoptions provided, which included skilled nursing facili-ties (83%), primary care providers (83%), acute rehabili-tation (73%), and geriatric clinics (67%). Outcomemeasures of effectiveness tracked by geriatric EDs areas follows: 73% track hospital admissions, 70% trackpatient satisfaction, 60% track hospital readmissions,57% track repeat ED visits, and 50% track both EDlength of stay and transfer to nursing homes and skillednursing facilities.

When asked what resources were currently lacking toimprove the operational efficiency of the geriatric ED,major themes cited by our respondents were therequirement for additional personnel and staff, need foreducational resources for staff, a desire for increasedadministration and institutional support, and needs foradditional space. Resources needed to improve patient-centric outcomes were cited as specialized geriatric EDpersonnel such as transfer coordinators and geriatricadvanced practice nurses. Additionally, respondents feltthat geriatric training of staff would improve patientoutcomes.

Table 1Physical Plant Changes

ChangePercentage of GeriatricEDs Making Change

Beds/mattresses 97Lighting 90Flooring skid/shine 83Visual aids 73Sound level 70Corridor safety 60Handrails 60Hearing aids 60Recliners 53Nourishment 43Other 47

Table 2Number of GED Physician Staff

All physicians cover both GEDandgeneralEDpatients

6.5%

Departments with ED physician assigned tocover only the GED

One 36.7%1.5 3.3%l-2 dependingontimeof day 3.3%1-3 dependingontime of day 3.3%2 20%4 6.6%No report 20.3%


DISCUSSION

The U.S. geriatric demographic imperative,64 in con-junction with a deteriorating primary care infrastruc-ture65 and unprecedented fiscal challenges, placesincreasing demands on the ED. Some of the immedi-ately measurable results of these pressures are aconstellation of elder care improvement strategies. Onesuch approach is the development of geriatric EDs. Todate, geriatric EDs have resulted from efforts of individ-ual institutions or have been established by owners ofmultiple hospital corporations. The preponderance ofgeriatric EDs in the Midwest is attributable to one mul-tihospital system, Trinity Health, which has developedgeriatric EDs throughout its member institutions. Thepreponderance of geriatric EDs in the Northeast wasnot addressed by our survey.

The constellation of geriatric EDs will vary with time,and identification of relevant informants is complex.Therefore, the snowball sample technique was used forgathering data from groups that are hidden or difficultto access. Even with this technique, identificationproved problematic. Internet searches yielded four self-identified geriatric EDs with which confirmatory contactcould not be established. Leads from professional orga-nizations produced three sites that denied or, uponreflection, felt that they did not operate a geriatric EDand one with which no contact was established. It islikely that this methodology did identify the majority ofpresent and planned geriatric EDs. However, any num-ber could begin operations in the near future.

The above failures of geriatric ED identification byEM professional organizations highlight the probabilitythat emergency physicians may not have a clear pictureof what constitutes a geriatric ED. Additionally, patientssearching for improved geriatric emergency care maynever identify the quality institutions they seek. Devel-opment of a clear definition of geriatric EDs is impera-tive to both the EM leaders shaping provision of thiscare and the patients seeking care. Our results clearlyshow that the definition of a geriatric ED remainselusive. Various components and models of geriatricEDs exist seemingly based on individual or expert opin-ion. No published best practices exist and no geriatricED offers proven outcome benefits. Many geriatric EDsshare operational features, personnel, policies, andprotocols similar enough that outcome data could becollected and analyzed. One additional long-term goalof this research is to improve the efficiency and reliabil-ity of high-quality emergency services for older adultsby defining the essential attributes of an effective geriat-ric ED, as well as delineating the key components likelyto improve individual targeted outcomes.

A research consortium to analyze the outcomes gen-erated by various geriatric ED interventions may be themost efficient manner to identify successful geriatric EDmodels of care. A regional, national, or internationalgeriatric ED research consortium could expedite theincorporation of key components into existing andfuture geriatric EDs. The advantages of establishing ageriatric ED research consortium include ease ofaccess between pertinent stakeholders to assess aware-ness,66 practice patterns,67 and regional variation in

outcomes.68 The ED is a unique laboratory to evaluateunderrepresented populations and acute disease pheno-types that may require different approaches to thedesign and conduct of research.69

This survey is a hypothesis-generating tool. Thedevelopers of the survey are familiar with the literatureon geriatric emergency care and attempted to identifycommon strategies employed in this population. Thesystematic application of these approaches throughgeriatric EDs generates opportunity for more intensiveevaluation in a high-yield target group. For example,more respondents identified existence of screening forcognitive and functional status and medication manage-ment than identified policies and protocols to addressthe same issues. A common problem in proactivescreening for problems is that positive screens may notbe linked with follow-up for issues that are identified.12

It is also interesting that time from inception of the geri-atric ED was not associated with an increase in selec-tions of any of the items. This suggests that geriatricEDs do not increase number of interventions offeredwith time. Many interesting follow-up issues arise as aresult of these survey descriptions.

Geriatric patients are a qualitatively distinct ED popu-lation with separate presentations, specific diagnosticrequirements, unique treatment strategies, particularsocial and disposition needs, and outcomes divergentfrom those of younger individuals.46,70,71 Geriatric EDdevelopment is comparable to prior efforts for the careof special populations such as pediatric EDs and Level Itrauma centers.72,73 Pediatric EM developed with theobjective to provide children with optimal emergencycare and outcomes after pediatric ED visits increaseddramatically between 1955 and 1971.72 The first stepoccurred in 1983 when ACEP hosted the InterspecialtyConference on Childhood Emergencies, which led tothe development of an advisory committee. In 1984,ACEP and the American Academy of Pediatrics (AAP)formed a joint task force, and in 1989 ACEP formed aSection of Pediatric EM. The first journal devoted topediatric EM (Pediatric Emergency Care) started inMarch 1985. In the late 1980s the American Board ofEmergency Medicine and the American Board of Pedi-atrics agreed that a subspecialty of pediatric EM shouldbe accessible to graduates of either EM or pediatric res-idencies via fellowship training. The purpose of certifi-cation in pediatric EM was “to improve and ensure thequality of patient care, teaching, and research in thearea of Pediatric Emergency Medicine.”74 The numberof pediatric EM fellowship programs increased rapidlyfrom 24 in 1988 to 43 in 1991 and 54 in 1994, with mostbased at children’s hospitals.72

The history of pediatric EM provides several lessonsfor geriatric EM. First, the impetus for advancing pedi-atric emergency training grew out of a rapidly expand-ing volume of these patients, similar to the growingawareness of a burgeoning geriatric population in theearly 21st century. Second, the process began in the1980s with active engagement of EM and pediatric spe-cialty societies, as well as the involvement of AmericanBoard of Medical Specialties certifying bodies. GeriatricEM will eventually require a similar certificationprocess. Third, most fellowship programs grew out of


pediatric hospitals, emphasizing the need to developgeriatric EDs to support specialty-training programs.Although we recognize the similarities between devel-oping pediatric and geriatric EM, we also note signifi-cant differences. Pediatrics was not in the midst of arapid decline in the availability of pediatricians in the1980s. The current decline of available geriatriciansplaces an unprecedented demand for quality geriatriccare in the hands of nongeriatrician physician provid-ers.75 In addition, pediatric EM did not arise during anera of increasingly constrained medical and medicaleducation resources, which defines our current reim-bursement environment.24,76 Nonetheless, pediatric EMprovides an important historical precedent from whichto learn as geriatric EM moves forward.

The geriatric ED may be identified as a process thatoccurs within the space of the general ED, as done withstroke centers and chest pain centers. The above mech-anisms for improved care of defined populations allunderwent various stages of development before ulti-mately seeking and gaining accreditation by externalagencies. Trauma centers are generally state-designatedwith criteria varying somewhat from state to state,although most use the American College of Surgeonscriteria and verification process. Stroke centers in moststates are certified by The Joint Commission,77 whilechest pain centers are certified by the Society of Cardio-vascular Patient Care.78

Identification of centers of excellence in care wasdeemed in the best interest of stroke patients by theAmerican Stroke Association, who in 2002 recom-mended the effectiveness of stroke center identificationvia self-assessment, verification, certification, andaccreditation.79 Approximately a decade later, The JointCommission reported high levels of interest amonginstitutions for stroke center certification.80 In 2003,leaders called for centers of excellence in acute myocar-dial infarction care.81 Systems and centers of care formyocardial infarction patients gained momentum in2007 with a consensus conference on systems for suchcare.82 In 2012, a proposal of a national cardiovascularemergency care system was published.83 While the out-come effect of certification per se has not been studied,there is ample evidence to conclude that stroke centercare is associated with improved patient outcomes84,85

and that better processes of care and greater number ofeligible patients receive thrombolysis in certified cen-ters.86 Additionally, regionalized systems accessingtrauma centers have reduced trauma morbidity andmortality,87,88 with higher level trauma centers yieldingthe best outcomes.89

The accreditation process itself signifies common defi-nitions and minimal criteria that must be met to qualifya center as providing superior care in a given area.Most certification criteria involve personnel withadvanced competence and continuing education and theexistence of policies, protocols, equipment, and opera-tions that augment care to the identified population.Currently, no criteria exist to define appropriate popula-tion, staffing, policies, or protocols for geriatric EDs. Ifthe specialty can assess outcomes improvement result-ing from centers of excellence in geriatric care, then theparallels with other specialized care centers suggest that

external certification for excellence in geriatric emer-gency care may be warranted.

However, the existing failures of quality ED eldercare, coupled with the rapid demographic increase,implies a need for expedited action.5–7 It took only10 years to establish stroke center certification, which isa targeted single disease process. It required about20 years developing certified pediatric EDs, as this certi-fication involves care of a population through a spec-trum of diseases. In contrast, leaders in an SAEM taskforce made multiple recommendations to improve EDelder care in 1992.1 In that same 20 years, EM has failedto develop a definitive answer to ensure improved geri-atric adult outcomes.8 For a specialty that is built onrapid response, our progress is comparably slow. Weshould incorporate lessons learned from the above spe-cial populations to ensure more prompt development ofevidence supporting geriatric ED care best practicesand outcomes. We must then disseminate and applythese solutions to enhance care for our elder popula-tion.90

If geriatric EDs are to become centers of excellenceor certified by external agencies, we must understandthe expected outcomes of these centers. Future effortsshould identify the services that are directly responsiblefor optimizing specific outcomes. A list of componentsenabling optimal geriatric outcomes could then be usedby external agencies to develop accredited geriatric EDsnationwide. The aging of the American population andtheir high utilization of emergency care is likely to accel-erate the development of geriatric EDs. We proposethat expert consensus from individual emergency physi-cians, their specialty societies, and interest groups withgeriatric expertise help guide the development of exist-ing and future geriatric EDs.

External certification may be needed to recognize andreward centers of excellence in geriatric emergencycare, define criteria for designation, and set minimumstandards of operation. Certification may help to moti-vate hospital leaders to invest in the personnel, training,and infrastructure that is essential for geriatric EDs,while guiding physicians seeking to establish thesecenters and serve the public good.

LIMITATIONS

The limitation inherent in a snowball sample is the fail-ure to identify one or more members in the target pop-ulation.91,92 The inherent variability of this samplepopulation created difficulty in describing features thatwere common or likely to appear. The survey instru-ment has not been validated for content or contextvalidity. We can neither ensure that responses reflectreality nor confirm that respondents interpreted queriesaccurately and consistently. It is possible that the major-ity of the population contains one or more items thatwere not asked in the survey instrument, and thereforesentinel features may have escaped description. It isalso possible that respondents did not understand indi-vidual survey questions in the same way, which couldresult in dissimilar responses. Frequency tables are notindicative of the population mean, as respondents wereable to select all the answers in a category that applied


to their institutions, and the exact number of observa-tions is unknown. This description reflects the state ofgeriatric EDs in this country at a particular point intime; geriatric EDs can rapidly implement new pro-cesses or eliminate others, and new geriatric EDs canbe created at any point.

CONCLUSIONS

The snowball sample identification of U.S. geriatric EDsresulted in 30 confirmed respondents. It is likely thistechnique identified the majority of existing geriatricEDs. There is significant variation in the componentsconstituting a geriatric ED. The United States shouldconsider external validation of self-identified geriatricEDs to standardize the quality and type of care patientscan expect from an institution with an identified geriat-ric ED.

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Supporting Information

The following supporting information is available in theonline version of this paper:

Data Supplement S1. The geriatric emergencydepartment survey instrument.

Data Supplement S2. Hospitals with confirmedgeriatric EDs.


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Academic Emergency Medicine on Geriatric EDs