A Profile of Acute Care in an Aging America: Snowball Sample Identification and Characterization of United States Geriatric Emergency Departments in 2013

Authors


  • Dr. Carpenter, an associate editor for this journal, had no role in the peer review or publication decision for this paper. The authors have no relevant financial information or potential conflicts of interest to disclose.

Abstract

Background

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

Objectives

The primary objective was to determine the number, distribution, and characteristics of geriatric EDs in the United States in 2013.

Methods

This was a survey with potential respondents identified via a snowball sampling of known geriatric EDs, EM professional organizations’ geriatric interest groups, and a structured search of the Internet using multiple search engines. Sites were contacted by telephone, and those confirming geriatric EDs 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 were reported 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 existing geriatric EDs, and six (20%) were planning to open geriatric EDs by 2014. The majority of geriatric EDs are located in the Midwest (46%) and Northeast (30%) regions of the United States. Eighty percent serve from 5,000 to 20,000 elder patients annually. Seventy percent of geriatric EDs are attached to the main ED, 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 percent have staff overlapping with the nongeriatric portion of their ED, and 80% require geriatric staff didactics. Sixty-seven percent of geriatric EDs report discharge planning for geriatric ED patients, and 90% of geriatric EDs had direct follow-up through patient callbacks.

Conclusions

The snowball sample identification of U.S. geriatric EDs resulted in 30 confirmed respondents. There is significant variation in the components constituting a geriatric ED. The United States should consider external validation of self-identified geriatric EDs to standardize the quality and type of care patients can expect from an institution with an identified geriatric ED.

Resumen

Introducción

El envejecimiento de Estados Unidos plantea una oportunidad para los servicios de urgencias (SU). Los estudios muestran que los pacientes ancianos tienen peores resultados a pesar de un mayor número de pruebas diagnósticas, periodos de observación prolongados y mayores porcentajes de ingreso. En respuesta, las máximas autoridades de la Medicina de Urgencias y Emergencias (MUE) han implementado estrategias para mejorar la atención del paciente anciano en los SU, mediante un incremento de los expertos, el equipamiento, las políticas y los protocolos. Un ejemplo es el desarrollo de SU geriátricos que ganan en popularidad en toda la nación. Según el conocimiento de los autores, ésta es la primera revisión que identifica de forma sistemática y caracteriza cualitativamente la existencia, la localización y las características de los SU geriátricos en Estados Unidos.

Objetivos

El objetivo principal fue determinar el número, la distribución y las características de los SU geriátricos en Estados Unidos en 2013.

Metodología

Se realizó una encuesta cuyos potenciales respondedores se identificaron mediante un muestreo de bola de nieve de los SU geriátricos conocidos, los grupos de interés geriátricos de las organizaciones profesionales de MUE y una búsqueda estructurada en internet mediante múltiples motores de búsqueda. Se contactó con los lugares mediante una llamada telefónica, y aquéllos que confirmaron la presencia de SU geriátricos recibieron la encuesta vía correo electrónico. Las preguntas categorizadas incluyeron fecha de apertura, localización, volúmenes, personal, cambios físicos de la planta, herramientas de despistaje, políticas y protocolos. Las categorías se documentaron en base a un interés general de aquéllos que buscaban comprender los componentes de un SU geriátrico.

Resultados

Treinta y seis hospitales confirmaron la existencia de un SU geriátrico y recibieron la encuesta. Treinta (80%) respondieron la encuesta y confirmaron la presencia de planes para el SU geriátrico: 24 (80%) tenían un SU geriátrico y seis (20%) estaban planeando abrirlo en 2014. La mayoría de los SU geriátricos están localizados en las regiones del medioeste (46%) y noreste (30%) de Estados Unidos. El 80% atiende de 5.000 a 20.000 ancianos anualmente; el 70% está junto al SU principal; y el 66% tiene de una a diez camas geriátricas. Los cambios físicos de la planta incluyen modificación de las camas (96%), iluminación (90%), suelos (83%) y recursos visuales (73%) y nivel de sonido (70%). El 77% tiene profesionales sanitarios entremezclados con una parte no geriátrica de su SU, y el 80% necesita personal geriátrico formado. EL 77% documentó planes de alta para los pacientes del SU geriátrico y un 90% tuvo seguimiento directo a través de llamadas a los pacientes.

Conclusiones

La identificación de los SU geriátricos a través de una muestra de bola de nieve resultó en 30 respuestas confirmatorias. Existe una variación significativa en los componentes que constituyen los SU geriátricos. Estados Unidos debería considerar una validación externa de los SU geriátricos propiamente identificados para estandarizar la calidad y el tipo de atención que los pacientes pueden esperar de una institución con un SU geriátrico identificado.

Current (and soon to be) older adults pose a significant challenge to the specialty of emergency medicine (EM).[1-4] Despite a trend favoring increased testing, prolonged periods of observation, and higher admission rates, studies have shown worse emergency department (ED) outcomes in this population.[5-7] In response to the geriatric demographic imperative, leaders from the Society for Academic Emergency Medicine (SAEM) and the American College of Emergency Physicians (ACEP) recommend modifying the model of emergency health care delivery to better care for older adults.[1, 8-10] Strategies for improved ED elder care range from the education and attitude change of emergency providers to the redesign of ED physical plants and departmental operational changes.[11-16]

One recent and evolving response to the aging demographic imperative is the development of geriatric EDs. The geriatric ED theoretically provides selected improvements in patient care through specialized services and environmental enhancements. The rationale in support of geriatric EDs includes inadequate EM graduate medical education in essential geriatric principles,[17] as well as insufficient recognition of geriatric syndromes such as dementia and delirium.[18-22] In addition, over the next two decades, the U.S. health care system will expend a significant and increasing proportion of medical capital on aging adults, so developing fiscally responsible alternatives to the status quo will become increasingly urgent.[23, 24]

The impetus to develop geriatric EDs varies.[25] Although little empiric evidence exists, some reasons include:

  1. Patient benefits such as establishment of more accurate diagnoses, improved therapies and health outcomes, better customer service, best practice protocols, improved safety, and enhanced satisfaction.[26]
  2. Hospital benefits such as marketing to attract higher reimbursement populations; growing a referral base for higher reimbursing hospital-based programs such as cardiac, neurologic, and orthopedic care; physical therapy services; otolaryngology; and falls centers.[27] The onus to prevent “never events” or iatrogenic complications such as urinary tract infection and decubitus ulcers begins in geriatric EDs or those caring for geriatric adults in emergency situations.[28] Additional benefits could include optimization of admission rates and length of stay and decreased readmissions.[29] More effective collaboration with nursing homes, skilled nursing facilities, emergency medical services, home services, and community resources are goals of geriatric EDs.[30] The expectation from cooperation of these institutions is for improved transitions of care, health care maintenance, injury prevention, and improved patient satisfaction.[31]
  3. Staff benefits including effective and efficient practices of care; increased satisfaction; focused education to enhance competence and clinical skills; and provision of resources such as equipment, tools, and effective protocols and policies to facilitate the work process.[27]

Although there are many reasons for a hospital to establish a geriatric ED, no established criteria yet exist to define a geriatric ED. To date, each hospital with a geriatric ED self-designates what defines its geriatric ED. Other terms connoting enhanced service to older adults, including “senior ED,” “geriatric-friendly,” and “elder ED,” are all undefined and not quantified. Current geriatric EDs range from simple marketing tools with little substance, to areas containing only isolated physical plant changes, to departments where unique personnel with geriatric training offer specialized services.

Thus far, scant published research exists to differentiate ED geriatric service provisions from general ED operations.[32, 33] Although experts hypothesize about the essential components of a high-quality geriatric ED,[34, 35] we provide early research to systematically identify and qualitatively characterize the existence, locations, and features of geriatric EDs across the United States. These descriptive details will be essential in understanding the variety of services offered and evaluation methods. Our primary objective was to determine the number, distribution, and characteristics of geriatric EDs.

Methods

Study Design and Population

This study was approved by the University of Chicago Institutional Review Board, with exemption from informed consent requirements. As depicted in Figure 1, from October 2012 through May 2013, the search for existing geriatric EDs was initiated by using a snowball sample[36] of seven known geriatric EDs. Snowball sampling is a nonprobability sampling technique in which identified study subjects recruit or identify other possible subjects from among their acquaintances or from potential subjects known by any means. It is a particularly useful sampling method for difficult to identify subjects and hidden populations such as drug dealers or illegal aliens. For our objectives, geriatric researchers and clinicians tend to know other geriatric researchers and clinicians, so snowball sampling serves to identify our subject population more completely. We coupled snowball sampling with Google, Bing, and PubMed Internet searches for the terms senior, geriatric, elder, and older adult linked with the terms emergency department or emergency services. E-mail snowball queries were sent to 17 institutions or individuals (where identified) generated by these initial identification strategies. This sample generated 22 possible sites. Multiple sample respondents named the entire membership 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 Geriatric EM Section (n = 140; http://www.acep.org/Content.aspx?id=25112), as likely sources that could identify potential geriatric EDs. Snowball identification prompted queries of the memberships of these two organizations via group listserves. Additionally, an in-person group query occurred during the 2012 ACEP Scientific Assembly Geriatric Section meeting. Through the snowball mechanism, the list of potential geriatric EDs grew to 46 hospitals. We contacted these sites or individuals by telephone to confirm geriatric ED existence and to identify at each a correspondent knowledgeable in the specifics of that geriatric ED's operations. Four hospitals stated that they did not operate geriatric EDs and were removed from the sample. No ED or administrative personnel for geriatric ED confirmation or sampling could be identified in six hospitals.

Figure 1.

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

Survey Content and Administration

The methodology of survey-based research has been described recently.[37] When possible, previously validated survey instruments are preferable,[38] but for our objectives, no such instrument exists. Therefore, our survey instrument was developed by a detailed review of existing research focused on ED interventions to improve geriatric adult emergency care,[5, 6, 13, 15, 20, 25, 26, 32, 34, 35, 39-46] as well as discussions with a multidisciplinary collaboration of representatives from SAEM, ACEP, the American Geriatrics Society, and the Emergency Nurses Association. This collaboration continues to develop geriatric ED infrastructure, personnel, protocol, and educational guidelines. The members of this collaborative workgroup helped to generate domains and questions for the survey. The University of Chicago Center for Research Informatics Bioinformatics Core (http://cri.uchicago.edu/?page_id=1185) assisted to assess survey ease of use and comprehensibility, as well as with the qualitative analysis of the survey.

Thirty-six hospitals confirmed geriatric EDs, and each identified one correspondent in the geriatric ED leadership. Each correspondent received a Research Electronic Data Capture (REDCap, http://www.project-redcap.org/) survey via e-mail. Respondents could win a geriatric EM textbook as remuneration for survey response. The survey contained a snowball sample question requesting identification of other geriatric EDs known to that individual. No additional geriatric EDs were identified through the survey. Reminder e-mails were sent weekly for 3 weeks to those who failed to respond. A research assistant contacted nonrespondents via telephone. Twenty institutions responded to the survey within the 3 weeks. The 16 that did not respond were contacted by telephone, with 10 subsequently completing the survey. Three did not respond, and three stated they did not operate geriatric EDs. The entire survey is available in Data Supplement S1 (available as supporting information in the online version of this paper).

Data Analysis

Primary data analysis was performed using SPSS Statistics version 21 (IBM SPSS, Armonk, NY). We summarized survey respondents and nonrespondents using a flow diagram.[37, 47] Frequency tables were created to characterize responses.[48] Categories were reported based on general interest to those seeking to understand components of a geriatric ED or as most applicable to hospitals planning future geriatric EDs. Categories include date of opening and location, geriatric patient volumes, number of general ED and geriatric ED beds, physical plant changes, patient selection, staffing qualifications and education, policies and protocols, screening and assessment tools, linkage to community services, and referral to clinical programs or services.

Results

We surveyed 36 hospitals as detailed in Figure 1. Thirty hospitals responded and confirmed geriatric ED existence. Respondents consisted of 43% physicians, 50% nurses, and 7% administrators. Three other sites did not have geriatric EDs, and we were unable to establish contact in another three. The response rate was thus 83%. Of the 30 respondents confirming presence of or plans for a geriatric ED, 24 had existing geriatric EDs, and six were planning to open geriatric EDs. The list of 30 respondents confirming geriatric EDs is attached as Data Supplement S2 (available as supporting information in the online version of this paper).

The first two geriatric EDs opened in 2008, two opened in 2009, five in 2010, 10 in 2011, seven in 2012, and three in 2013. At the completion of this survey, one identified institution planned to open a geriatric ED in 2014. The geographic locales of existing geriatric EDs are displayed in Figure 2.

Figure 2.

Geriatric ED (GED) locations across the United States.

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

As described in Table 1, physical plant changes are common among the geriatric EDs: all but one reported changes to their beds or mattresses, while 90% reported making modifications to lighting. Respondents also reported enhancements for corridor safety, flooring, handrails, and sound levels, as well as use of hearing and visual aids.

Table 1. Physical Plant Changes
ChangePercentage of Geriatric EDs Making Change
Beds/mattresses97
Lighting90
Flooring skid/shine83
Visual aids73
Sound level70
Corridor safety60
Handrails60
Hearing aids60
Recliners53
Nourishment43
Other47

The majority of geriatric EDs select an age cutoff of 65 years and older for placement in the geriatric ED. In addition to age, 60% of geriatric EDs use the Emergency Severity Index (ESI) score[49] for appropriate geriatric ED placement. Most send patients with ESI Level 1 to the main ED for evaluation and stabilization, and 40% use the discretion of the triage nurse prior to placement of patients in the geriatric ED. Seventeen percent use geriatric-specific screening in the assignment of patients to the geriatric ED.

Seventy-seven percent of geriatric EDs have staff that overlap with the main ED. Eighty percent report that there are special qualifications and/or educational requirements for geriatric ED staff. Many provide geriatric ED staff with special training, such as didactics for physicians and the Geriatric Nurse Education (GENE) training course from the Emergency Nurses Association[50] for nursing staff. Nursing staff and advanced practice registered nurses (APRNs) are most likely to be uniquely assigned to the geriatric ED with no general ED responsibilities. Those sites with specialized geriatric ED personnel most commonly use APRNs, geriatric nurse liaisons, case managers, and palliative care consultants. Physician staffing assignments to the geriatric ED are listed in Table 2. In addition to provision and education of staff, it is important to note that geriatric ED personnel may selectively spend time on geriatric-specific tasks such as screening and assessment, transitions of care, and medication management.

Table 2. Number of GED Physician Staff
All physicians cover both GEDandgeneralED patients6.5%
Departments with ED physician assigned to cover only the GED 
One36.7%
1.53.3%
l-2 dependingontimeof day3.3%
1-3 dependingontime of day3.3%
220%
46.6%
No report20.3%

Most geriatric EDs (87%) reported screening for at least one of four categories of geriatric syndromes. The most commonly used screening tools in geriatric EDs are cognitive (77%) and functional status (73%) screens, followed by high-risk screening (63%) and medication management (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 Screening Tool.[55] The most commonly used screening tool for medication management was reference to the Beers List of inappropriate medications for elders.[56] The most common policies and protocols implemented for geriatric ED operations include falls prevention (57%),[57] medication 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 solicit direct follow-up through patient callbacks. Targeted interventions to improve health care outcomes are common: 70% have ED staff arrange coordination of outpatient community resource services, while 63% coordinate outpatient hospital services. Pharmacology review is used by 73% to prevent adverse drug reactions, 67% report discharge planning for ED elders, and 60% report communication with the patient's primary care physician.

Many geriatric EDs reported that they provide patients with extensive post-ED resources. Ninety-three percent provide linkage to community services, such as home aids (80%), home equipment (73%), and physical therapy (70%). All geriatric EDs also reported postdischarge referral to at least one of the clinical service options provided, which included skilled nursing facilities (83%), primary care providers (83%), acute rehabilitation (73%), and geriatric clinics (67%). Outcome measures of effectiveness tracked by geriatric EDs are as follows: 73% track hospital admissions, 70% track patient satisfaction, 60% track hospital readmissions, 57% track repeat ED visits, and 50% track both ED length of stay and transfer to nursing homes and skilled nursing facilities.

When asked what resources were currently lacking to improve the operational efficiency of the geriatric ED, major themes cited by our respondents were the requirement for additional personnel and staff, need for educational resources for staff, a desire for increased administration and institutional support, and needs for additional space. Resources needed to improve patient-centric outcomes were cited as specialized geriatric ED personnel such as transfer coordinators and geriatric advanced practice nurses. Additionally, respondents felt that geriatric training of staff would improve patient outcomes.

Discussion

The U.S. geriatric demographic imperative,[64] in conjunction with a deteriorating primary care infrastructure[65] and unprecedented fiscal challenges, places increasing demands on the ED. Some of the immediately measurable results of these pressures are a constellation of elder care improvement strategies. One such approach is the development of geriatric EDs. To date, geriatric EDs have resulted from efforts of individual institutions or have been established by owners of multiple hospital corporations. The preponderance of geriatric EDs in the Midwest is attributable to one multihospital system, Trinity Health, which has developed geriatric EDs throughout its member institutions. The preponderance of geriatric EDs in the Northeast was not 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 for gathering data from groups that are hidden or difficult to access. Even with this technique, identification proved problematic. Internet searches yielded four self-identified geriatric EDs with which confirmatory contact could not be established. Leads from professional organizations produced three sites that denied or, upon reflection, felt that they did not operate a geriatric ED and one with which no contact was established. It is likely that this methodology did identify the majority of present and planned geriatric EDs. However, any number could begin operations in the near future.

The above failures of geriatric ED identification by EM professional organizations highlight the probability that emergency physicians may not have a clear picture of what constitutes a geriatric ED. Additionally, patients searching for improved geriatric emergency care may never identify the quality institutions they seek. Development of a clear definition of geriatric EDs is imperative to both the EM leaders shaping provision of this care and the patients seeking care. Our results clearly show that the definition of a geriatric ED remains elusive. Various components and models of geriatric EDs exist seemingly based on individual or expert opinion. No published best practices exist and no geriatric ED offers proven outcome benefits. Many geriatric EDs share operational features, personnel, policies, and protocols similar enough that outcome data could be collected and analyzed. One additional long-term goal of this research is to improve the efficiency and reliability of high-quality emergency services for older adults by defining the essential attributes of an effective geriatric ED, as well as delineating the key components likely to improve individual targeted outcomes.

A research consortium to analyze the outcomes generated by various geriatric ED interventions may be the most efficient manner to identify successful geriatric ED models of care. A regional, national, or international geriatric ED research consortium could expedite the incorporation of key components into existing and future geriatric EDs. The advantages of establishing a geriatric ED research consortium include ease of access between pertinent stakeholders to assess awareness,[66] practice patterns,[67] and regional variation in outcomes.[68] The ED is a unique laboratory to evaluate underrepresented populations and acute disease phenotypes that may require different approaches to the design and conduct of research.[69]

This survey is a hypothesis-generating tool. The developers of the survey are familiar with the literature on geriatric emergency care and attempted to identify common strategies employed in this population. The systematic application of these approaches through geriatric EDs generates opportunity for more intensive evaluation in a high-yield target group. For example, more respondents identified existence of screening for cognitive and functional status and medication management than identified policies and protocols to address the same issues. A common problem in proactive screening for problems is that positive screens may not be linked with follow-up for issues that are identified.[12] It is also interesting that time from inception of the geriatric ED was not associated with an increase in selections of any of the items. This suggests that geriatric EDs do not increase number of interventions offered with time. Many interesting follow-up issues arise as a result of these survey descriptions.

Geriatric patients are a qualitatively distinct ED population with separate presentations, specific diagnostic requirements, unique treatment strategies, particular social and disposition needs, and outcomes divergent from those of younger individuals.[46, 70, 71] Geriatric ED development is comparable to prior efforts for the care of special populations such as pediatric EDs and Level I trauma centers.[72, 73] Pediatric EM developed with the objective to provide children with optimal emergency care and outcomes after pediatric ED visits increased dramatically between 1955 and 1971.[72] The first step occurred in 1983 when ACEP hosted the Interspecialty Conference on Childhood Emergencies, which led to the 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 a Section of Pediatric EM. The first journal devoted to pediatric EM (Pediatric Emergency Care) started in March 1985. In the late 1980s the American Board of Emergency Medicine and the American Board of Pediatrics agreed that a subspecialty of pediatric EM should be accessible to graduates of either EM or pediatric residencies via fellowship training. The purpose of certification in pediatric EM was “to improve and ensure the quality of patient care, teaching, and research in the area of Pediatric Emergency Medicine.”[74] The number of pediatric EM fellowship programs increased rapidly from 24 in 1988 to 43 in 1991 and 54 in 1994, with most based at children's hospitals.[72]

The history of pediatric EM provides several lessons for geriatric EM. First, the impetus for advancing pediatric emergency training grew out of a rapidly expanding volume of these patients, similar to the growing awareness of a burgeoning geriatric population in the early 21st century. Second, the process began in the 1980s with active engagement of EM and pediatric specialty societies, as well as the involvement of American Board of Medical Specialties certifying bodies. Geriatric EM will eventually require a similar certification process. Third, most fellowship programs grew out of pediatric hospitals, emphasizing the need to develop geriatric EDs to support specialty-training programs. Although we recognize the similarities between developing pediatric and geriatric EM, we also note significant differences. Pediatrics was not in the midst of a rapid decline in the availability of pediatricians in the 1980s. The current decline of available geriatricians places an unprecedented demand for quality geriatric care in the hands of nongeriatrician physician providers.[75] In addition, pediatric EM did not arise during an era of increasingly constrained medical and medical education resources, which defines our current reimbursement environment.[24, 76] Nonetheless, pediatric EM provides an important historical precedent from which to learn as geriatric EM moves forward.

The geriatric ED may be identified as a process that occurs within the space of the general ED, as done with stroke centers and chest pain centers. The above mechanisms for improved care of defined populations all underwent various stages of development before ultimately seeking and gaining accreditation by external agencies. Trauma centers are generally state-designated with criteria varying somewhat from state to state, although most use the American College of Surgeons criteria and verification process. Stroke centers in most states are certified by The Joint Commission,[77] while chest pain centers are certified by the Society of Cardiovascular Patient Care.[78]

Identification of centers of excellence in care was deemed in the best interest of stroke patients by the American Stroke Association, who in 2002 recommended the effectiveness of stroke center identification via self-assessment, verification, certification, and accreditation.[79] Approximately a decade later, The Joint Commission reported high levels of interest among institutions for stroke center certification.[80] In 2003, leaders called for centers of excellence in acute myocardial infarction care.[81] Systems and centers of care for myocardial infarction patients gained momentum in 2007 with a consensus conference on systems for such care.[82] In 2012, a proposal of a national cardiovascular emergency care system was published.[83] While the outcome effect of certification per se has not been studied, there is ample evidence to conclude that stroke center care is associated with improved patient outcomes[84, 85] and that better processes of care and greater number of eligible patients receive thrombolysis in certified centers.[86] Additionally, regionalized systems accessing trauma centers have reduced trauma morbidity and mortality,[87, 88] with higher level trauma centers yielding the best outcomes.[89]

The accreditation process itself signifies common definitions and minimal criteria that must be met to qualify a center as providing superior care in a given area. Most certification criteria involve personnel with advanced competence and continuing education and the existence of policies, protocols, equipment, and operations that augment care to the identified population. Currently, no criteria exist to define appropriate population, staffing, policies, or protocols for geriatric EDs. If the specialty can assess outcomes improvement resulting from centers of excellence in geriatric care, then the parallels with other specialized care centers suggest that external certification for excellence in geriatric emergency care may be warranted.

However, the existing failures of quality ED elder care, coupled with the rapid demographic increase, implies a need for expedited action.[5-7] It took only 10 years to establish stroke center certification, which is a targeted single disease process. It required about 20 years developing certified pediatric EDs, as this certification involves care of a population through a spectrum of diseases. In contrast, leaders in an SAEM task force made multiple recommendations to improve ED elder care in 1992.[1] In that same 20 years, EM has failed to develop a definitive answer to ensure improved geriatric adult outcomes.[8] For a specialty that is built on rapid response, our progress is comparably slow. We should incorporate lessons learned from the above special populations to ensure more prompt development of evidence supporting geriatric ED care best practices and outcomes. We must then disseminate and apply these solutions to enhance care for our elder population.[90]

If geriatric EDs are to become centers of excellence or certified by external agencies, we must understand the expected outcomes of these centers. Future efforts should identify the services that are directly responsible for optimizing specific outcomes. A list of components enabling optimal geriatric outcomes could then be used by external agencies to develop accredited geriatric EDs nationwide. The aging of the American population and their high utilization of emergency care is likely to accelerate the development of geriatric EDs. We propose that expert consensus from individual emergency physicians, their specialty societies, and interest groups with geriatric expertise help guide the development of existing and future geriatric EDs.

External certification may be needed to recognize and reward centers of excellence in geriatric emergency care, define criteria for designation, and set minimum standards of operation. Certification may help to motivate hospital leaders to invest in the personnel, training, and infrastructure that is essential for geriatric EDs, while guiding physicians seeking to establish these centers and serve the public good.

Limitations

The limitation inherent in a snowball sample is the failure to identify one or more members in the target population.[91, 92] The inherent variability of this sample population created difficulty in describing features that were common or likely to appear. The survey instrument has not been validated for content or context validity. We can neither ensure that responses reflect reality nor confirm that respondents interpreted queries accurately and consistently. It is possible that the majority of the population contains one or more items that were not asked in the survey instrument, and therefore sentinel features may have escaped description. It is also possible that respondents did not understand individual survey questions in the same way, which could result in dissimilar responses. Frequency tables are not indicative of the population mean, as respondents were able to select all the answers in a category that applied to their institutions, and the exact number of observations is unknown. This description reflects the state of geriatric EDs in this country at a particular point in time; geriatric EDs can rapidly implement new processes or eliminate others, and new geriatric EDs can be created at any point.

Conclusions

The snowball sample identification of U.S. geriatric EDs resulted in 30 confirmed respondents. It is likely this technique identified the majority of existing geriatric EDs. There is significant variation in the components constituting a geriatric ED. The United States should consider external validation of self-identified geriatric EDs to standardize the quality and type of care patients can expect from an institution with an identified geriatric ED.

Ancillary