Michael Stern, MD

Case

A 100-year-old woman with a history of hypertension, hypothyroidism, and moderate Alzheimer dementia was brought to the ED by emergency medical services (EMS) for altered mental status after her home health aide (HHA) noted a change in the patient’s behavior. For the past few days, the patient’s appetite waned, and she became progressively more lethargic, not eating for over 24 hours. The aide activated 911 on the direction of the patient’s primary care physician. There were no reported changes to the patient’s medications which included aspirin, levothyroxine, and hydrochlorothiazide. She was unable to provide any meaningful history. 

On arrival to the ED, the patient appeared comfortable in bed. She was sleepy, but easily aroused. Initial vital signs were: heart rate, 110 beats/minute; respiratory rate, 12 breaths/minute; blood pressure, 163/103 mm Hg; oral temperature, 98.2˚F. Oxygen (O₂) saturation was 96% on room air. She was oriented to person only and responded appropriately to simple questions, intermittently following one-step commands. She was unable to attend and required redirection throughout the interview. (According to the aide, this behavior was different than her baseline.)

The patient’s head and neck examination were notable for some mild, boggy, periorbital edema and dry mucous membranes. Her thyroid examination was normal; her lungs were clear; and her cardiac examination revealed a 2/6 systolic ejection murmur over the second right intercostal space. Examination of the abdomen, extremities, and skin was unrevealing, and there were no gross focal neurological deficits. Her reflexes were normal throughout. 

Initial assessment of this patient suggested a diagnosis of dementia and hypoactive delirium—the latter due to one or more of several possible etiologies.

Altered Mental Status

While altered mental status is a billable medical ICD-9-CM code¹ used to specify a diagnosis on a reimbursement claim, it is not a disease state itself. Instead, it is a catchall phrase that incorporates any change in mental status, encompassing symptomatology that may have the largest differential diagnosis encountered in emergency medicine.

Delirium
An important category of altered mental status is delirium. The diagnostic criteria² for delirium in DSM-V have remained essentially unchanged from DSM-IV; however, the prevalence of delirium as one of the key geriatric syndromes has grown as a result of increased research and education, particularly in the emergency medical setting. Distilled down, delirium can be defined as an acute change in mental status not caused by underlying dementia. Its cause is often multifactorial, and it is frequently an underappreciated consequence of both critical illness and the hospital environment.³

Delirium is an emergency unto itself, with an in-hospital mortality rate mirroring that of sepsis or acute myocardial infarction.⁴ The older-adult population is especially at risk of delirium and can present with one of three clinical subtypes: hyperactive (ie, agitated, etc), hypoactive (ie, somnolent, lethargic, stuporous, etc), and mixed type.⁵

Delirium is a form of acute brain dysfunction involving a complex interaction between patient vulnerability factors and precipitating factors,^6,7 resulting in either impaired cerebral metabolism and/or neurotransmitter disequilibrium. Both sets of factors must be considered. For example, delirium may develop in a particularly vulnerable 92-year-old man with moderate dementia and a mild lower leg cellulitis without signs of sepsis.

The composition of factors precipitating the onset of delirium includes age, dementia, alcohol use, depression, illness severity, and drug exposure—notably benzodiazepines, opiates, and medications with anticholinergic properties.⁸ While major precipitants or causes of delirium, traditionally considered as potentially life-threatening acute events, are well known (Table 1), others are often overlooked (Table 2). Yet, ironically, these more frequently bypassed causes are more readily reversible, once discovered, such as inadequate pain control, urinary retention, constipation, dehydration, polypharmacy, and negative environmental conditions in the patient’s immediate surroundings. These findings have recently been corroborated.⁹

Hypoactive or “quiet” delirium is particularly difficult to detect because of the lack of agitation, and can therefore make the evaluation of the underlying precipitant especially challenging.

The Confusion Assessment Method
Identifying delirium can be a particular challenge for emergency physicians (EPs), especially when the patient has an underlying diagnosis of dementia and the specific degree of cognitive impairment is not known. The Confusion Assessment Method (CAM)¹⁰ is the most commonly used tool in the critical care setting11 and is the only validated tool for the ED, with an 86% sensitivity and 100% specificity.12 It evaluates four elements: (1) acute onset and fluctuating course; (2) inattention; (3) disorganized thinking; and (4) altered level of consciousness. A patient must demonstrate the first two elements in addition to either the third or fourth element to be considered to have delirium.¹⁰

The CAM intensive care unit scale has the potential to be even more applicable in the ED. Recent findings support its validation.⁹

 

Case Continued

With respect to the elderly patient in this case with dementia and multiple potential causes for hypoactive delirium, the life-saving measure was the New York City (NYC) mandate that all 911 responding EMS workers wear ambient carbon monoxide (CO) detectors. Though the value of these detectors is controversial due to their low sensitivity, the emergency medical technicians (EMTs) detected an elevated CO level of 300 ppm when they arrived at the patient’s home.

Without this information, the patient’s age and clinical presentation would almost certainly have prompted an extensive evaluation to determine the etiology of her change in mental status and most likely would have missed the true cause of CO toxicity, which was confirmed by venous co-oximetry showing the patient to have a carboxyhemoglobin (HbCO) level of 19.5%.

Carbon Monoxide Toxicity

Carbon monoxide affects multiple cell types. It binds to myoglobin and in high concentrations depresses myocardial contractility. In platelets, CO displaces nitric oxide potentially resulting in vasodilation. Life-threatening CO poisoning causes hypotension, syncope, tachycardia, and an altered mental status. Delayed neuropsychiatric sequelae also may occur as the result of free radical injury to the brain.¹³

Symptoms
Patients with chronic CO poisoning who can adequately communicate may report nausea, headache, lightheadedness, and lethargy mimicking other seasonal illnesses. In debilitated or cognitively impaired patients who are unable to communicate, findings may include tachycardia, a mild change in mental status, and little else. Prolonged exposure and physiologic accumulation of CO may cause depressed mental status, coma, or death.

Although HbCO levels are confirmatory of exposure, venous levels do not necessarily reflect tissue concentrations or outcomes. Patients with a similar level to that of this patient (19.5%) may present with no symptoms, mild headache, or a deep coma depending on the duration of exposure to CO. 

Definitive treatment is removal from the toxic environment and prompt administration of O₂. In some cases, hyperbaric therapy may be beneficial.¹⁴

Diagnosis
Although CO exposure is the most common cause of poisoning death worldwide, its detection requires a high index of suspicion, especially in areas where public-health protection measures are absent.

Although CO exposure is the most common cause of poisoning death worldwide, its detection requires a high index of suspicion, especially in areas where public-health protection measures are absent.

It is rarely easy to diagnose the first case of an illness of which one is unfamiliar or not accustomed to treating. Likewise, it is very difficult to consider, diagnose and, as a result, effectively manage the first presentation of a known condition that is typically seasonal or linked to a different geographic location. Acute presentations of environmental exposures, illicit drug poisonings, and communicable infectious diseases are increasingly the purview of emergency medicine. Whether it is the first case of Ebola, of severe acute respiratory syndrome, the influenza virus, a new lethal street drug overdose, or CO poisoning prior to the onset of winter, maintaining a high index of suspicion for the “index case” is of paramount importance. The patient presented here, the first CO poisoning of the season at the authors’ institution, illustrates the responsibility the EP to consider, diagnose, and prevent a wide-range of deadly consequences—injury prevention as the result of vigilance. Moreover, the consequences of missing the diagnosis would have placed others at risk for continued poisoning and possibly death.

Portable and Ambient Carboxyhemoglobin Monitors

The NYC Department of Health (NYCDOH) requires that all EMTs and paramedics wear CO detectors and all residential housing contain CO monitors. The NYCDOH also mandates that all identified cases of CO poisoning be reported to the NYC Poison Control Center. This centralization of data on any and all patients exposed to CO can result in an investigation of the source of CO by the fire department and capture symptomatic patients who present for care outside of the 911 response system. The source of CO in this patient was ultimately traced to a faulty furnace that was repaired to prevent others in the building from becoming victims of CO poisoning.

It should be noted that portable noninvasive HbCO monitors may be inadequate to rule out CO poisoning as the sensitivity of such devices can be as low as 48%.¹⁵ Carbon monoxide poisoning can result from brief exposure to a high ambient concentration, such as a fire in which environmental concentrations may exceed 500 ppm or more insidiously, in a setting of a chronic exposure. Faulty furnaces—a common seasonal cause of CO poisoning—may continue to produce adequate heat and fail to prompt any concerns.

Since CO is colorless and odorless, ambient CO detectors stationed in the home are the best means of alerting one to exposure. In this case, though mandated by NYCDOH, a CO detector was not present in the patient’s home.

 

Case Conclusion

Through the rapid identification of CO poisoning in this elderly patient with altered mental status, EMS was able to evacuate the building while bringing the elderly tenant and her home attendant to the ED.

Based on the elderly patient’s elevated HbCO level, she was treated with O₂ and discharged from the hospital the following day feeling well. In addition to the patient’s symptoms, when the aide was interviewed, she reported that she had been experiencing daily headaches, which she said soon resolved on departure from her client’s house. Her symptoms had been bothersome, but not so severe as to prompt her to seek medical attention. The aide was found to have an HbCO level of 12.5% and was discharged from the ED after 6 hours of observation and O₂ therapy. The third occupant of the building, a tenant, was also brought to the ED and found to have an HbCO level of 12%. The tenant was treated with O₂ therapy and discharged to home.

Dr Caldwell is an assistant professor of medicine in the department of emergency medicine, New York Presbyterian Hospital/Weill Cornell Medical Center, New York. Dr Rao is an assistant professor of emergency medicine; and the chief in the division of medical Toxicology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York. Dr Stern is an assistant professor of medicine, department of emergency medicine; chief of geriatric emergency medicine; and codirector of geriatric emergency medicine fellowship at New York Presbyterian Hospital/Weill Cornell Medical Center, New York.

Case

A 100-year-old woman with a history of hypertension, hypothyroidism, and moderate Alzheimer dementia was brought to the ED by emergency medical services (EMS) for altered mental status after her home health aide (HHA) noted a change in the patient’s behavior. For the past few days, the patient’s appetite waned, and she became progressively more lethargic, not eating for over 24 hours. The aide activated 911 on the direction of the patient’s primary care physician. There were no reported changes to the patient’s medications which included aspirin, levothyroxine, and hydrochlorothiazide. She was unable to provide any meaningful history. 

On arrival to the ED, the patient appeared comfortable in bed. She was sleepy, but easily aroused. Initial vital signs were: heart rate, 110 beats/minute; respiratory rate, 12 breaths/minute; blood pressure, 163/103 mm Hg; oral temperature, 98.2˚F. Oxygen (O₂) saturation was 96% on room air. She was oriented to person only and responded appropriately to simple questions, intermittently following one-step commands. She was unable to attend and required redirection throughout the interview. (According to the aide, this behavior was different than her baseline.)

The patient’s head and neck examination were notable for some mild, boggy, periorbital edema and dry mucous membranes. Her thyroid examination was normal; her lungs were clear; and her cardiac examination revealed a 2/6 systolic ejection murmur over the second right intercostal space. Examination of the abdomen, extremities, and skin was unrevealing, and there were no gross focal neurological deficits. Her reflexes were normal throughout. 

Initial assessment of this patient suggested a diagnosis of dementia and hypoactive delirium—the latter due to one or more of several possible etiologies.

Altered Mental Status

While altered mental status is a billable medical ICD-9-CM code¹ used to specify a diagnosis on a reimbursement claim, it is not a disease state itself. Instead, it is a catchall phrase that incorporates any change in mental status, encompassing symptomatology that may have the largest differential diagnosis encountered in emergency medicine.

Delirium
An important category of altered mental status is delirium. The diagnostic criteria² for delirium in DSM-V have remained essentially unchanged from DSM-IV; however, the prevalence of delirium as one of the key geriatric syndromes has grown as a result of increased research and education, particularly in the emergency medical setting. Distilled down, delirium can be defined as an acute change in mental status not caused by underlying dementia. Its cause is often multifactorial, and it is frequently an underappreciated consequence of both critical illness and the hospital environment.³

Delirium is an emergency unto itself, with an in-hospital mortality rate mirroring that of sepsis or acute myocardial infarction.⁴ The older-adult population is especially at risk of delirium and can present with one of three clinical subtypes: hyperactive (ie, agitated, etc), hypoactive (ie, somnolent, lethargic, stuporous, etc), and mixed type.⁵

Delirium is a form of acute brain dysfunction involving a complex interaction between patient vulnerability factors and precipitating factors,^6,7 resulting in either impaired cerebral metabolism and/or neurotransmitter disequilibrium. Both sets of factors must be considered. For example, delirium may develop in a particularly vulnerable 92-year-old man with moderate dementia and a mild lower leg cellulitis without signs of sepsis.

The composition of factors precipitating the onset of delirium includes age, dementia, alcohol use, depression, illness severity, and drug exposure—notably benzodiazepines, opiates, and medications with anticholinergic properties.⁸ While major precipitants or causes of delirium, traditionally considered as potentially life-threatening acute events, are well known (Table 1), others are often overlooked (Table 2). Yet, ironically, these more frequently bypassed causes are more readily reversible, once discovered, such as inadequate pain control, urinary retention, constipation, dehydration, polypharmacy, and negative environmental conditions in the patient’s immediate surroundings. These findings have recently been corroborated.⁹

Hypoactive or “quiet” delirium is particularly difficult to detect because of the lack of agitation, and can therefore make the evaluation of the underlying precipitant especially challenging.

The Confusion Assessment Method
Identifying delirium can be a particular challenge for emergency physicians (EPs), especially when the patient has an underlying diagnosis of dementia and the specific degree of cognitive impairment is not known. The Confusion Assessment Method (CAM)¹⁰ is the most commonly used tool in the critical care setting11 and is the only validated tool for the ED, with an 86% sensitivity and 100% specificity.12 It evaluates four elements: (1) acute onset and fluctuating course; (2) inattention; (3) disorganized thinking; and (4) altered level of consciousness. A patient must demonstrate the first two elements in addition to either the third or fourth element to be considered to have delirium.¹⁰

The CAM intensive care unit scale has the potential to be even more applicable in the ED. Recent findings support its validation.⁹

 

Case Continued

With respect to the elderly patient in this case with dementia and multiple potential causes for hypoactive delirium, the life-saving measure was the New York City (NYC) mandate that all 911 responding EMS workers wear ambient carbon monoxide (CO) detectors. Though the value of these detectors is controversial due to their low sensitivity, the emergency medical technicians (EMTs) detected an elevated CO level of 300 ppm when they arrived at the patient’s home.

Without this information, the patient’s age and clinical presentation would almost certainly have prompted an extensive evaluation to determine the etiology of her change in mental status and most likely would have missed the true cause of CO toxicity, which was confirmed by venous co-oximetry showing the patient to have a carboxyhemoglobin (HbCO) level of 19.5%.

Carbon Monoxide Toxicity

Carbon monoxide affects multiple cell types. It binds to myoglobin and in high concentrations depresses myocardial contractility. In platelets, CO displaces nitric oxide potentially resulting in vasodilation. Life-threatening CO poisoning causes hypotension, syncope, tachycardia, and an altered mental status. Delayed neuropsychiatric sequelae also may occur as the result of free radical injury to the brain.¹³

Symptoms
Patients with chronic CO poisoning who can adequately communicate may report nausea, headache, lightheadedness, and lethargy mimicking other seasonal illnesses. In debilitated or cognitively impaired patients who are unable to communicate, findings may include tachycardia, a mild change in mental status, and little else. Prolonged exposure and physiologic accumulation of CO may cause depressed mental status, coma, or death.

Although HbCO levels are confirmatory of exposure, venous levels do not necessarily reflect tissue concentrations or outcomes. Patients with a similar level to that of this patient (19.5%) may present with no symptoms, mild headache, or a deep coma depending on the duration of exposure to CO. 

Definitive treatment is removal from the toxic environment and prompt administration of O₂. In some cases, hyperbaric therapy may be beneficial.¹⁴

Diagnosis
Although CO exposure is the most common cause of poisoning death worldwide, its detection requires a high index of suspicion, especially in areas where public-health protection measures are absent.

Although CO exposure is the most common cause of poisoning death worldwide, its detection requires a high index of suspicion, especially in areas where public-health protection measures are absent.

It is rarely easy to diagnose the first case of an illness of which one is unfamiliar or not accustomed to treating. Likewise, it is very difficult to consider, diagnose and, as a result, effectively manage the first presentation of a known condition that is typically seasonal or linked to a different geographic location. Acute presentations of environmental exposures, illicit drug poisonings, and communicable infectious diseases are increasingly the purview of emergency medicine. Whether it is the first case of Ebola, of severe acute respiratory syndrome, the influenza virus, a new lethal street drug overdose, or CO poisoning prior to the onset of winter, maintaining a high index of suspicion for the “index case” is of paramount importance. The patient presented here, the first CO poisoning of the season at the authors’ institution, illustrates the responsibility the EP to consider, diagnose, and prevent a wide-range of deadly consequences—injury prevention as the result of vigilance. Moreover, the consequences of missing the diagnosis would have placed others at risk for continued poisoning and possibly death.

Portable and Ambient Carboxyhemoglobin Monitors

The NYC Department of Health (NYCDOH) requires that all EMTs and paramedics wear CO detectors and all residential housing contain CO monitors. The NYCDOH also mandates that all identified cases of CO poisoning be reported to the NYC Poison Control Center. This centralization of data on any and all patients exposed to CO can result in an investigation of the source of CO by the fire department and capture symptomatic patients who present for care outside of the 911 response system. The source of CO in this patient was ultimately traced to a faulty furnace that was repaired to prevent others in the building from becoming victims of CO poisoning.

It should be noted that portable noninvasive HbCO monitors may be inadequate to rule out CO poisoning as the sensitivity of such devices can be as low as 48%.¹⁵ Carbon monoxide poisoning can result from brief exposure to a high ambient concentration, such as a fire in which environmental concentrations may exceed 500 ppm or more insidiously, in a setting of a chronic exposure. Faulty furnaces—a common seasonal cause of CO poisoning—may continue to produce adequate heat and fail to prompt any concerns.

Since CO is colorless and odorless, ambient CO detectors stationed in the home are the best means of alerting one to exposure. In this case, though mandated by NYCDOH, a CO detector was not present in the patient’s home.

 

Case Conclusion

Through the rapid identification of CO poisoning in this elderly patient with altered mental status, EMS was able to evacuate the building while bringing the elderly tenant and her home attendant to the ED.

Based on the elderly patient’s elevated HbCO level, she was treated with O₂ and discharged from the hospital the following day feeling well. In addition to the patient’s symptoms, when the aide was interviewed, she reported that she had been experiencing daily headaches, which she said soon resolved on departure from her client’s house. Her symptoms had been bothersome, but not so severe as to prompt her to seek medical attention. The aide was found to have an HbCO level of 12.5% and was discharged from the ED after 6 hours of observation and O₂ therapy. The third occupant of the building, a tenant, was also brought to the ED and found to have an HbCO level of 12%. The tenant was treated with O₂ therapy and discharged to home.

Dr Caldwell is an assistant professor of medicine in the department of emergency medicine, New York Presbyterian Hospital/Weill Cornell Medical Center, New York. Dr Rao is an assistant professor of emergency medicine; and the chief in the division of medical Toxicology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York. Dr Stern is an assistant professor of medicine, department of emergency medicine; chief of geriatric emergency medicine; and codirector of geriatric emergency medicine fellowship at New York Presbyterian Hospital/Weill Cornell Medical Center, New York.

Case

A 100-year-old woman with a history of hypertension, hypothyroidism, and moderate Alzheimer dementia was brought to the ED by emergency medical services (EMS) for altered mental status after her home health aide (HHA) noted a change in the patient’s behavior. For the past few days, the patient’s appetite waned, and she became progressively more lethargic, not eating for over 24 hours. The aide activated 911 on the direction of the patient’s primary care physician. There were no reported changes to the patient’s medications which included aspirin, levothyroxine, and hydrochlorothiazide. She was unable to provide any meaningful history. 

On arrival to the ED, the patient appeared comfortable in bed. She was sleepy, but easily aroused. Initial vital signs were: heart rate, 110 beats/minute; respiratory rate, 12 breaths/minute; blood pressure, 163/103 mm Hg; oral temperature, 98.2˚F. Oxygen (O₂) saturation was 96% on room air. She was oriented to person only and responded appropriately to simple questions, intermittently following one-step commands. She was unable to attend and required redirection throughout the interview. (According to the aide, this behavior was different than her baseline.)

The patient’s head and neck examination were notable for some mild, boggy, periorbital edema and dry mucous membranes. Her thyroid examination was normal; her lungs were clear; and her cardiac examination revealed a 2/6 systolic ejection murmur over the second right intercostal space. Examination of the abdomen, extremities, and skin was unrevealing, and there were no gross focal neurological deficits. Her reflexes were normal throughout. 

Initial assessment of this patient suggested a diagnosis of dementia and hypoactive delirium—the latter due to one or more of several possible etiologies.

Altered Mental Status

While altered mental status is a billable medical ICD-9-CM code¹ used to specify a diagnosis on a reimbursement claim, it is not a disease state itself. Instead, it is a catchall phrase that incorporates any change in mental status, encompassing symptomatology that may have the largest differential diagnosis encountered in emergency medicine.

Delirium
An important category of altered mental status is delirium. The diagnostic criteria² for delirium in DSM-V have remained essentially unchanged from DSM-IV; however, the prevalence of delirium as one of the key geriatric syndromes has grown as a result of increased research and education, particularly in the emergency medical setting. Distilled down, delirium can be defined as an acute change in mental status not caused by underlying dementia. Its cause is often multifactorial, and it is frequently an underappreciated consequence of both critical illness and the hospital environment.³

Delirium is an emergency unto itself, with an in-hospital mortality rate mirroring that of sepsis or acute myocardial infarction.⁴ The older-adult population is especially at risk of delirium and can present with one of three clinical subtypes: hyperactive (ie, agitated, etc), hypoactive (ie, somnolent, lethargic, stuporous, etc), and mixed type.⁵

Delirium is a form of acute brain dysfunction involving a complex interaction between patient vulnerability factors and precipitating factors,^6,7 resulting in either impaired cerebral metabolism and/or neurotransmitter disequilibrium. Both sets of factors must be considered. For example, delirium may develop in a particularly vulnerable 92-year-old man with moderate dementia and a mild lower leg cellulitis without signs of sepsis.

The composition of factors precipitating the onset of delirium includes age, dementia, alcohol use, depression, illness severity, and drug exposure—notably benzodiazepines, opiates, and medications with anticholinergic properties.⁸ While major precipitants or causes of delirium, traditionally considered as potentially life-threatening acute events, are well known (Table 1), others are often overlooked (Table 2). Yet, ironically, these more frequently bypassed causes are more readily reversible, once discovered, such as inadequate pain control, urinary retention, constipation, dehydration, polypharmacy, and negative environmental conditions in the patient’s immediate surroundings. These findings have recently been corroborated.⁹

Hypoactive or “quiet” delirium is particularly difficult to detect because of the lack of agitation, and can therefore make the evaluation of the underlying precipitant especially challenging.

The Confusion Assessment Method
Identifying delirium can be a particular challenge for emergency physicians (EPs), especially when the patient has an underlying diagnosis of dementia and the specific degree of cognitive impairment is not known. The Confusion Assessment Method (CAM)¹⁰ is the most commonly used tool in the critical care setting11 and is the only validated tool for the ED, with an 86% sensitivity and 100% specificity.12 It evaluates four elements: (1) acute onset and fluctuating course; (2) inattention; (3) disorganized thinking; and (4) altered level of consciousness. A patient must demonstrate the first two elements in addition to either the third or fourth element to be considered to have delirium.¹⁰

The CAM intensive care unit scale has the potential to be even more applicable in the ED. Recent findings support its validation.⁹

 

Case Continued

With respect to the elderly patient in this case with dementia and multiple potential causes for hypoactive delirium, the life-saving measure was the New York City (NYC) mandate that all 911 responding EMS workers wear ambient carbon monoxide (CO) detectors. Though the value of these detectors is controversial due to their low sensitivity, the emergency medical technicians (EMTs) detected an elevated CO level of 300 ppm when they arrived at the patient’s home.

Without this information, the patient’s age and clinical presentation would almost certainly have prompted an extensive evaluation to determine the etiology of her change in mental status and most likely would have missed the true cause of CO toxicity, which was confirmed by venous co-oximetry showing the patient to have a carboxyhemoglobin (HbCO) level of 19.5%.

Carbon Monoxide Toxicity

Carbon monoxide affects multiple cell types. It binds to myoglobin and in high concentrations depresses myocardial contractility. In platelets, CO displaces nitric oxide potentially resulting in vasodilation. Life-threatening CO poisoning causes hypotension, syncope, tachycardia, and an altered mental status. Delayed neuropsychiatric sequelae also may occur as the result of free radical injury to the brain.¹³

Symptoms
Patients with chronic CO poisoning who can adequately communicate may report nausea, headache, lightheadedness, and lethargy mimicking other seasonal illnesses. In debilitated or cognitively impaired patients who are unable to communicate, findings may include tachycardia, a mild change in mental status, and little else. Prolonged exposure and physiologic accumulation of CO may cause depressed mental status, coma, or death.

Although HbCO levels are confirmatory of exposure, venous levels do not necessarily reflect tissue concentrations or outcomes. Patients with a similar level to that of this patient (19.5%) may present with no symptoms, mild headache, or a deep coma depending on the duration of exposure to CO. 

Definitive treatment is removal from the toxic environment and prompt administration of O₂. In some cases, hyperbaric therapy may be beneficial.¹⁴

Diagnosis
Although CO exposure is the most common cause of poisoning death worldwide, its detection requires a high index of suspicion, especially in areas where public-health protection measures are absent.

Although CO exposure is the most common cause of poisoning death worldwide, its detection requires a high index of suspicion, especially in areas where public-health protection measures are absent.

It is rarely easy to diagnose the first case of an illness of which one is unfamiliar or not accustomed to treating. Likewise, it is very difficult to consider, diagnose and, as a result, effectively manage the first presentation of a known condition that is typically seasonal or linked to a different geographic location. Acute presentations of environmental exposures, illicit drug poisonings, and communicable infectious diseases are increasingly the purview of emergency medicine. Whether it is the first case of Ebola, of severe acute respiratory syndrome, the influenza virus, a new lethal street drug overdose, or CO poisoning prior to the onset of winter, maintaining a high index of suspicion for the “index case” is of paramount importance. The patient presented here, the first CO poisoning of the season at the authors’ institution, illustrates the responsibility the EP to consider, diagnose, and prevent a wide-range of deadly consequences—injury prevention as the result of vigilance. Moreover, the consequences of missing the diagnosis would have placed others at risk for continued poisoning and possibly death.

Portable and Ambient Carboxyhemoglobin Monitors

The NYC Department of Health (NYCDOH) requires that all EMTs and paramedics wear CO detectors and all residential housing contain CO monitors. The NYCDOH also mandates that all identified cases of CO poisoning be reported to the NYC Poison Control Center. This centralization of data on any and all patients exposed to CO can result in an investigation of the source of CO by the fire department and capture symptomatic patients who present for care outside of the 911 response system. The source of CO in this patient was ultimately traced to a faulty furnace that was repaired to prevent others in the building from becoming victims of CO poisoning.

It should be noted that portable noninvasive HbCO monitors may be inadequate to rule out CO poisoning as the sensitivity of such devices can be as low as 48%.¹⁵ Carbon monoxide poisoning can result from brief exposure to a high ambient concentration, such as a fire in which environmental concentrations may exceed 500 ppm or more insidiously, in a setting of a chronic exposure. Faulty furnaces—a common seasonal cause of CO poisoning—may continue to produce adequate heat and fail to prompt any concerns.

Since CO is colorless and odorless, ambient CO detectors stationed in the home are the best means of alerting one to exposure. In this case, though mandated by NYCDOH, a CO detector was not present in the patient’s home.

 

Case Conclusion

Through the rapid identification of CO poisoning in this elderly patient with altered mental status, EMS was able to evacuate the building while bringing the elderly tenant and her home attendant to the ED.

Based on the elderly patient’s elevated HbCO level, she was treated with O₂ and discharged from the hospital the following day feeling well. In addition to the patient’s symptoms, when the aide was interviewed, she reported that she had been experiencing daily headaches, which she said soon resolved on departure from her client’s house. Her symptoms had been bothersome, but not so severe as to prompt her to seek medical attention. The aide was found to have an HbCO level of 12.5% and was discharged from the ED after 6 hours of observation and O₂ therapy. The third occupant of the building, a tenant, was also brought to the ED and found to have an HbCO level of 12%. The tenant was treated with O₂ therapy and discharged to home.

Dr Caldwell is an assistant professor of medicine in the department of emergency medicine, New York Presbyterian Hospital/Weill Cornell Medical Center, New York. Dr Rao is an assistant professor of emergency medicine; and the chief in the division of medical Toxicology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York. Dr Stern is an assistant professor of medicine, department of emergency medicine; chief of geriatric emergency medicine; and codirector of geriatric emergency medicine fellowship at New York Presbyterian Hospital/Weill Cornell Medical Center, New York.

Case 1 

An 82-year-old man presented to the ED accompanied by his son, who stated that his father “had not been acting right” for the past 2 days. The patient was combative, yelling “Go away,” and was intermittently more confused than his baseline; he was also eating and drinking less than usual. He had a history of mild dementia, noninsulin-dependent diabetes, hypertension, and arthritis; there were no recent changes in his medication. The patient lived alone in an apartment across the hall from his son and had home healthcare aide 4 hours a day, 3 days a week. He was independent of activities of daily living (ADL), but needed help with shopping and cooking. 

At presentation, the patient’s vital signs were: temperature, afebrile; heart rate (HR), 94 beats/minute; blood pressure (BP), 146/92 mm hg; respiratory rate (RR), 22 breaths/minute. Oxygen (O₂) saturation was 96% on room air. A finger-stick glucose test was 103 mg/dL. He was hyperalert and agitated, and did not appear oriented to place or time. There were no focal neurological deficits; mucous membranes were mildly dry; and faint crackles were heard at the right base of the lungs. The patient was placed on a monitor in a curtained room in the ED, and was given 2 L O2 via nasal cannula, which improved O2 saturation to 99%. With his son present, an intravenous (IV) line was placed and blood was drawn. An electrocardiogram (ECG) showed a sinus rhythm without ischemic findings.

During evaluation, the patient continued to pull at the monitor lines and attempted to get off the stretcher. To calm his agitation, he was given haloperidol 2.5 mg and lorazepam 1 mg; 10 minutes after administration, he became sedated and difficult to arouse. His vital signs remained stable.

Laboratory analysis revealed a white blood cell count (WBC) of 12.5 K/uL, a negative troponin, a brain natriuretic peptide (BNP) of 80 pg/mL, and normal blood urea nitrogen (BUN) and creatinine levels. Urinalysis was negative for infection, but chest X-ray showed a right lower lobe infiltrate. Blood cultures were drawn, and the patient was continued on maintenance fluids and started on IV antibiotics to cover community-acquired pneumonia. He was admitted to the hospital for pneumonia and altered mental status.

As the patient’s sedative state was followed by periods of agitation, he was treated with additional haloperidol and lorazepam by the inpatient medical team, which resulted in further sedation. On hospital day 3, his urinary output decreased. He was given an IV bolus of 3 L normal saline over 6 hours, after which his mental status began to improve, and he was switched to oral antibiotics. His mental status returned to baseline and O₂ saturation was 99% on room air. He was discharged home on hospital day 5 accompanied by his son.

Case 2

A 75-year-old man was brought to the ED with a 3-day history of worsening dyspnea on exertion, increased orthopnea, and increased bilateral lower extremity edema. He had a history of congestive heart failure (CHF), with an ejection fraction of 40%, and had been on 40 mg of furosemide daily at home; there were no recent changes to his medication. The patient was independent of ADL at baseline, living with his wife in a home with stairs. 

His vital signs at presentation were: temperature, afebrile; HR, 86 beats/minute; BP, 160/90 mm hg; RR 30 breaths/minute; O₂ saturation was 92% on room air. The patient had increased work of breathing and was speaking in four- to five-word sentences. Pulmonary examination revealed crackles half way up bilaterally. He also had 2+ pitting edema bilaterally in his lower extremities. He was otherwise alert and oriented.  

On 4 L O₂ via nasal cannula, the patient’s O₂ saturation was 98%.  Laboratory analysis revealed a BNP of 600 pg/mL, negative troponin, and normal creatinine level. Urinalysis was negative for evidence of infection. An ECG showed no changes, and chest X-ray revealed mild pulmonary congestion without an infiltrate. In the ED, an indwelling urinary catheter (IUC) was placed to monitor urinary output before the patient was given 40 mg of IV furosemide for diuresis. The patient was then admitted for management of exacerbation of CHF. As the medical team was preparing to discharge him on hospital day 2, his wife noticed that he was confused and not acting “like himself.” An investigation for causes of delirium included evaluation for infectious disease, which revealed an elevated WBC of 14.0 K/uL, stable creatinine; and urinalysis positive for bacteria, WBCs, leukocyte esterase, and nitrites. Since chest X-ray showed resolution of the vascular congestion, the patient no longer required supplemental O₂.

 

The IUC was removed, and the patient was started on IV antibiotics for a urinary tract infection (UTI) secondary to IUC placement. The inpatient stay was prolonged for an additional 3 days until his delirium cleared and he could be continued on oral antibiotics as an outpatient.

Discussion

There is nothing extraordinary about these two cases. Every day elderly adults present to EDs throughout the country with confusion caused by pneumonia and dehydration that is sometimes initially attributed to worsening dementia and then complicated or prolonged by overuse of powerful sedating medications. Also, complications resulting from IUCs inserted in the ED all too often prolong hospitalizations. But by using protocols designed for better, more efficient emergency care of elderly patients, their ED care can be substantially improved and any subsequent inpatient care shortened.

The older adult population (ages 65 years and older) often presents to the ED with similar complaints to their younger counterparts—eg, chest pain, abdominal pain, dyspnea. However, the history, physical examination, and social assessment of elderly patients usually lead to a more comprehensive work-up, as older adults tend to present in an atypical fashion for both illness and trauma, thus necessitating a broader differential. In addition, they are more susceptible to adverse reactions from medications and procedures.

Regardless of the ultimate diagnosis, simply presenting to an ED as a patient (and sometimes spending many hours there) places older adults at elevated risk of morbidity and mortality. The challenge is to develop reliable tools to streamline the management of this population in order to increase diagnostic accuracy, decrease adverse events, and improve patient outcomes.

Clinical Protocols
Clinical protocols are one way in which we can educate and standardize the practice of multiple levels of provider, including nurses, midlevel providers, and physicians. Adopting protocols is natural for EPs—the key is to make sure the clinical protocol to be implemented is designed or modified for the ED setting in which it will be implemented.

In our ED, we have recently implemented the following two protocols for common scenarios in older adults: (1) assessment and management of delirium; and (2) decreased use of IUCs. These protocols employ the following stepwise project plan:

1. Focus groups involving nurses, midlevels, residents, and attendings to assess ED provider knowledge, attitudes, and practice patterns regarding the clinical issue  in older adult patients, and to guide development of the clinical protocol by understanding needs and constraints of the current ED environment;
2. An extensive literature review of the clinical topic;
3. Development of the clinical protocol by the workgroup;
4. Implementation of protocol after multiple educational sessions using a scripted slide presentation to ensure all providers receive the same information; and
5. Subsequent data analysis from the electronic medical record to assess the impact (ie, outcome) of the protocol.

Delirium
Delirium is a common syndrome in older adults, but is often unrecognized despite its clinical importance. Although 7% to 17% of older adults who present to the ED suffer from delirium,^1-6 emergency physicians (EPs) miss 64% to 83% of cases, and 12% to 38% of patients with unrecognized delirium are actually discharged from the ED.^1,6-8 Unfortunately, patients discharged from the ED with undetected delirium are three times more likely to die within 3 months than those whose delirium was recognized.

Life-threatening causes are more apt to be recognized early on in the ED. With this in mind, we developed a new, comprehensive, evidence-based protocol for recognition, diagnosis, management, and disposition of agitated delirium in older adults in the ED, with a focus on identifying and treating the commonly missed contributing causes: analgesia, bladder-urine retention, constipation, dehydration, environment, and medications.⁹

IUC Placement in the ED
The second protocol implemented at our institution is a new, evidence-based protocol for the placement, management, and reassessment of IUCs. As emphasized by the National American College of Emergency Physicians (ACEP) 2013 Choosing Wisely Campaign,¹⁰ inserting an IUC is a procedure that should be undertaken judiciously as it is associated with an elevated risk of infection, delirium, falls, and other adverse events. As of 2008, the Centers for Medicare and Medicaid Services no longer reimburses for hospital-acquired catheter-associated UTIs.¹¹

After conducting focus groups of our ED providers, we learned that IUCs are placed more frequently than needed—often for reasons of convenience—and are rarely reassessed or removed if the patient is admitted to the hospital. Thus, our protocol highlights appropriate, possibly appropriate, and inappropriate indications for IUC placement, with an emphasis on trying alternative modes of urine collection, communicating among healthcare providers regarding the necessity of an IUC, and reassessment of the patient for IUC removal.

 

Our protocols have yielded early promising results, but further research is underway to determine their specific impact. The goal is to create a protocol that is feasible and effective for the specific institution and department to which it is applied. By ensuring all members of the healthcare team are involved in the development and design of a protocol, there is ownership of its implementation and use, with the overarching goal of improving patient care.

Geriatric ED Guidelines
In the beginning of 2014, new consensus-based Geriatric Emergency Department (GED) guidelines were published in order to “provide a standardized set of guidelines that can effectively improve the care of the geriatric population and are feasible to implement in the ED.”¹² These guidelines are the result of a 2-year effort by representatives from ACEP, the American Geriatrics Society, the Society of Academic Emergency Medicine, and the Emergency Nurses Association, who were committed to optimizing the emergency-care delivery model for geriatrics. The participants encompassed both academic and community providers and included clinicians and researchers. These guidelines were formulated based on an 80% consensus among the representatives and, when possible, validated using existing literature at the time.

The genesis of the GED guidelines was multifactorial. In addition to the formation and rapid growth of geriatric interest groups and sections within EM academic organizations over the last 14 years, as well as the development of geriatric core competencies for EM residents in training, the 2010 Census Data results sharply outlined the details of the rapidly growing population of older adults in the United States. This acted as an alarm highlighting the need for a structured document containing best practice recommendations from geriatric emergency healthcare providers, researchers, and advocates. “The subsequent increased need for healthcare for this burgeoning geriatric population represents an unprecedented and overwhelming challenge to the American healthcare system as a whole and to emergency departments specifically,” the authors of the GED guidelines noted.

In response to a growing national interest in geriatric ED patients and an ever-increasing competition to attract patients from this demographic by EDs across the country, there has been a surge of self-designated GEDs during the last few years. Currently, more than 70 hospitals claim to have GEDs, raising the question of what sort of geriatric patient care is actually being delivered in these EDs. The question is of increased importance because very few of these “GEDs” are in academic centers or are associated with thought leaders in EM. In fact, when 30 self-designated GEDs that were snowball sampled in 2013 by researchers who asked what specific changes they had made toward the goal of improving care for the elderly, several rescinded this self-designation.

Because of heightened concerns for the needs of the increasing geriatric population overall, and the rise in the proportion of ED visits by this demographic, the authors of the GED guidelines state that “the contemporary emergency medicine management model may not be adequate for geriatric adults,” and offer the new GED guidelines as a basis on which EDs can consider ways to improve care for older adults while addressing the unique needs of this population. The GED guidelines propose specific methods and processes by which ED care of the elderly can be optimized. The authors note that “similar programs designed for other age groups (pediatrics) or directed towards specific diseases (STEMI, stroke, and trauma) have improved the care both in individual EDs and system-wide, resulting in better, more cost-effective care and ultimately better patient outcomes.”

The GED guidelines consist of 40 specific recommendations in six general categories: (1) staffing/administration; (2) equipment/supplies; (3) education; (4) policies/procedures/protocols; (5) follow-up/transitions of care; and (6) quality-improvement measures. This template outlines how to construct an effective GED program. The following highlights recommendations for each of these categories:

Staffing/Administration. Set qualifications and responsibilities for the medical director, nurse manager, staff physicians, nurses, and specialists, as well as accessibility to specialist ancillary services, with the goal of establishing hospital site-specific staff and coordination of local resources.

Equipment/Supplies. Develop potential physical and structural enhancements that address issues of mobility, comfort, safety, and behavioral needs (including memory cues and sensorial perception) while decreasing iatrogenic complications, such as the development of pressure ulcers (eg, the use of reclining chairs and pressure-redistributing foam mattresses).

Education. Provide nurse and clinical provider education and specialty-specific training focusing on contemporary, research-based geriatric-specific material, with regular assessment for interdisciplinary core competencies.

Policies/Procedures/Protocols. Implement a directed, comprehensive approach to facilitate screening and assessment of geriatric patients for added needs/post-ED adverse outcomes, as well as validated, ED-feasible screening tools/instruments for delirium and dementia, medication management, falls, use of urinary catheters, and the provision of palliative care.

 

Follow-up/Transitions of Care. Design discharge processes best suited for older patients (eg, large-font instructions), as well as collaborate with community resources to provide home-health services and home safety assessment in order to facilitate care following discharge.

Quality Improvement. Implement a system to collect and monitor pertinent and prevalent geriatric emergency care indicators (eg, incidence of injurious falls and documentation of fall risk assessment) designed to increase staff education and program success.

The authors clearly state that the GED guidelines represent recommendations. They are not a mandate for every ED, nor are they a list that requires 100% compliance. Instead, the document provides the potential steps to be taken, the rationale for these recommendations, and an outline of the resources available to aid in the transition from theory to implementation in any ED. The goal is to ensure better, safer, and age-appropriate treatment. In summary, these guidelines represent an effort to improve and even transform emergency care for older adults on the brink of one of the most significant challenges facing our healthcare system both in and beyond the ED.

Moving forward, the authors of the GED guidelines have defined a plan that “includes dissemination, implementation, adaptation, and refinement.” In addition to approval by each of the organization’s board of directors and the copyright of the material in 2013, the ED guidelines have now been widely disseminated through publication in numerous news articles (including international publications) and discussions on satellite radio. Tracking of new GEDs is planned. In addition, the prioritization of the guidelines is underway using a modified Delphi method, with the express purpose of assessing the relative potential benefits and harms associated with each recommendation by providing a weighted list from most important to least important.

A “Geriatric Emergency Department Boot Camp” is being developed to bring the recommendations to hospitals interested in “geriatricizing” their EDs. Geriatric EM leaders will act as consultants, providing training and a toolbox of resources. Specific reviews and revisions of the GED guidelines will take place in a 4- to 5-year cycle. Clearly, a next important step is the development of a GED certification system based on outcome studies of the individual components.

Criticisms of the GED guidelines have already been voiced among some EM providers. Specific concerns include a fear of partitioning the ED (as has occurred with pediatrics); an increase in cost and decreased efficiency; the need to maintain general expertise among EM physicians; the lack of evidence-based data upon which the recommendations were made; the fact that some guidelines were extrapolated from other clinical settings; and the belief that these changes will be too logistically difficult and take too much time.

The fact remains that the wave of geriatric patients (the “silver tsunami”) is already beginning to hit the shores of our hospitals. And GEDs are already here to help absorb the impact. The lack of iron-clad evidence for many of the recommendations should not be an absolute obstacle, but rather part of the natural evolution and improvement of similar endeavors. Nor should GEDs contain empty beds while younger adults sit in the waiting room, or conversely, force the elderly to wait for space in the GED when there are empty beds in the main ED. Ideally, the GED should be the location where the ED staff can implement these guidelines, which they can afterwards utilize in any part of the ED. These guidelines are designed to provide the best available expert opinion on how to deliver better geriatric care in the ED. The imperative for this goal is clear and necessitates this educated “leap-of-faith.” Change is never easy and often comes with an upfront cost of time, resources, and money. Moreover, there is nothing in a well-designed GED that may not also benefit, or at least will not adversely affect care of a younger adult as well. Therefore, flexibility and optimal utilization of space in a busy ED need not be sacrificed.

Conclusion

To improve diagnostic evaluation and care of the increasing number of geriatric patients presenting to the ED, reliable tools, protocols, and guidelines must be developed and implemented to ensure diagnostic accuracy, decrease adverse events, and improve patient outcomes. Fortunately, the new GED consensus guidelines are flexible and do not need to be wholly embraced—lending themselves to modifications and institution-specific adoptions. The “protocolization” and implementation of the guidelines may improve patient flow, operational efficiency, and, most importantly, the quality of care delivered. And likely, these guidelines will provide the foundation for future education and research into the improved emergency care of older adults.

 

The GED guidelines can be accessed at http://www.saem.org/docs/education/geri_ed_guidelines_final.pdf?sfvrsn=2.

Dr Stern is an assistant professor of medicine and codirector, geriatric emergency medicine fellowship, department of emergency medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York; and an assistant attending physician, department of emergency medicine, New York-Presbyterian Hospital.
Dr Mulcare is an instructor of medicine and an assistant attending physician, department of emergency medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York. She is a former fellow of geriatric emergency medicine.

Case 1 

An 82-year-old man presented to the ED accompanied by his son, who stated that his father “had not been acting right” for the past 2 days. The patient was combative, yelling “Go away,” and was intermittently more confused than his baseline; he was also eating and drinking less than usual. He had a history of mild dementia, noninsulin-dependent diabetes, hypertension, and arthritis; there were no recent changes in his medication. The patient lived alone in an apartment across the hall from his son and had home healthcare aide 4 hours a day, 3 days a week. He was independent of activities of daily living (ADL), but needed help with shopping and cooking. 

At presentation, the patient’s vital signs were: temperature, afebrile; heart rate (HR), 94 beats/minute; blood pressure (BP), 146/92 mm hg; respiratory rate (RR), 22 breaths/minute. Oxygen (O₂) saturation was 96% on room air. A finger-stick glucose test was 103 mg/dL. He was hyperalert and agitated, and did not appear oriented to place or time. There were no focal neurological deficits; mucous membranes were mildly dry; and faint crackles were heard at the right base of the lungs. The patient was placed on a monitor in a curtained room in the ED, and was given 2 L O2 via nasal cannula, which improved O2 saturation to 99%. With his son present, an intravenous (IV) line was placed and blood was drawn. An electrocardiogram (ECG) showed a sinus rhythm without ischemic findings.

During evaluation, the patient continued to pull at the monitor lines and attempted to get off the stretcher. To calm his agitation, he was given haloperidol 2.5 mg and lorazepam 1 mg; 10 minutes after administration, he became sedated and difficult to arouse. His vital signs remained stable.

Laboratory analysis revealed a white blood cell count (WBC) of 12.5 K/uL, a negative troponin, a brain natriuretic peptide (BNP) of 80 pg/mL, and normal blood urea nitrogen (BUN) and creatinine levels. Urinalysis was negative for infection, but chest X-ray showed a right lower lobe infiltrate. Blood cultures were drawn, and the patient was continued on maintenance fluids and started on IV antibiotics to cover community-acquired pneumonia. He was admitted to the hospital for pneumonia and altered mental status.

As the patient’s sedative state was followed by periods of agitation, he was treated with additional haloperidol and lorazepam by the inpatient medical team, which resulted in further sedation. On hospital day 3, his urinary output decreased. He was given an IV bolus of 3 L normal saline over 6 hours, after which his mental status began to improve, and he was switched to oral antibiotics. His mental status returned to baseline and O₂ saturation was 99% on room air. He was discharged home on hospital day 5 accompanied by his son.

Case 2

A 75-year-old man was brought to the ED with a 3-day history of worsening dyspnea on exertion, increased orthopnea, and increased bilateral lower extremity edema. He had a history of congestive heart failure (CHF), with an ejection fraction of 40%, and had been on 40 mg of furosemide daily at home; there were no recent changes to his medication. The patient was independent of ADL at baseline, living with his wife in a home with stairs. 

His vital signs at presentation were: temperature, afebrile; HR, 86 beats/minute; BP, 160/90 mm hg; RR 30 breaths/minute; O₂ saturation was 92% on room air. The patient had increased work of breathing and was speaking in four- to five-word sentences. Pulmonary examination revealed crackles half way up bilaterally. He also had 2+ pitting edema bilaterally in his lower extremities. He was otherwise alert and oriented.  

On 4 L O₂ via nasal cannula, the patient’s O₂ saturation was 98%.  Laboratory analysis revealed a BNP of 600 pg/mL, negative troponin, and normal creatinine level. Urinalysis was negative for evidence of infection. An ECG showed no changes, and chest X-ray revealed mild pulmonary congestion without an infiltrate. In the ED, an indwelling urinary catheter (IUC) was placed to monitor urinary output before the patient was given 40 mg of IV furosemide for diuresis. The patient was then admitted for management of exacerbation of CHF. As the medical team was preparing to discharge him on hospital day 2, his wife noticed that he was confused and not acting “like himself.” An investigation for causes of delirium included evaluation for infectious disease, which revealed an elevated WBC of 14.0 K/uL, stable creatinine; and urinalysis positive for bacteria, WBCs, leukocyte esterase, and nitrites. Since chest X-ray showed resolution of the vascular congestion, the patient no longer required supplemental O₂.

 

The IUC was removed, and the patient was started on IV antibiotics for a urinary tract infection (UTI) secondary to IUC placement. The inpatient stay was prolonged for an additional 3 days until his delirium cleared and he could be continued on oral antibiotics as an outpatient.

Discussion

There is nothing extraordinary about these two cases. Every day elderly adults present to EDs throughout the country with confusion caused by pneumonia and dehydration that is sometimes initially attributed to worsening dementia and then complicated or prolonged by overuse of powerful sedating medications. Also, complications resulting from IUCs inserted in the ED all too often prolong hospitalizations. But by using protocols designed for better, more efficient emergency care of elderly patients, their ED care can be substantially improved and any subsequent inpatient care shortened.

The older adult population (ages 65 years and older) often presents to the ED with similar complaints to their younger counterparts—eg, chest pain, abdominal pain, dyspnea. However, the history, physical examination, and social assessment of elderly patients usually lead to a more comprehensive work-up, as older adults tend to present in an atypical fashion for both illness and trauma, thus necessitating a broader differential. In addition, they are more susceptible to adverse reactions from medications and procedures.

Regardless of the ultimate diagnosis, simply presenting to an ED as a patient (and sometimes spending many hours there) places older adults at elevated risk of morbidity and mortality. The challenge is to develop reliable tools to streamline the management of this population in order to increase diagnostic accuracy, decrease adverse events, and improve patient outcomes.

Clinical Protocols
Clinical protocols are one way in which we can educate and standardize the practice of multiple levels of provider, including nurses, midlevel providers, and physicians. Adopting protocols is natural for EPs—the key is to make sure the clinical protocol to be implemented is designed or modified for the ED setting in which it will be implemented.

In our ED, we have recently implemented the following two protocols for common scenarios in older adults: (1) assessment and management of delirium; and (2) decreased use of IUCs. These protocols employ the following stepwise project plan:

1. Focus groups involving nurses, midlevels, residents, and attendings to assess ED provider knowledge, attitudes, and practice patterns regarding the clinical issue  in older adult patients, and to guide development of the clinical protocol by understanding needs and constraints of the current ED environment;
2. An extensive literature review of the clinical topic;
3. Development of the clinical protocol by the workgroup;
4. Implementation of protocol after multiple educational sessions using a scripted slide presentation to ensure all providers receive the same information; and
5. Subsequent data analysis from the electronic medical record to assess the impact (ie, outcome) of the protocol.

Delirium
Delirium is a common syndrome in older adults, but is often unrecognized despite its clinical importance. Although 7% to 17% of older adults who present to the ED suffer from delirium,^1-6 emergency physicians (EPs) miss 64% to 83% of cases, and 12% to 38% of patients with unrecognized delirium are actually discharged from the ED.^1,6-8 Unfortunately, patients discharged from the ED with undetected delirium are three times more likely to die within 3 months than those whose delirium was recognized.

Life-threatening causes are more apt to be recognized early on in the ED. With this in mind, we developed a new, comprehensive, evidence-based protocol for recognition, diagnosis, management, and disposition of agitated delirium in older adults in the ED, with a focus on identifying and treating the commonly missed contributing causes: analgesia, bladder-urine retention, constipation, dehydration, environment, and medications.⁹

IUC Placement in the ED
The second protocol implemented at our institution is a new, evidence-based protocol for the placement, management, and reassessment of IUCs. As emphasized by the National American College of Emergency Physicians (ACEP) 2013 Choosing Wisely Campaign,¹⁰ inserting an IUC is a procedure that should be undertaken judiciously as it is associated with an elevated risk of infection, delirium, falls, and other adverse events. As of 2008, the Centers for Medicare and Medicaid Services no longer reimburses for hospital-acquired catheter-associated UTIs.¹¹

After conducting focus groups of our ED providers, we learned that IUCs are placed more frequently than needed—often for reasons of convenience—and are rarely reassessed or removed if the patient is admitted to the hospital. Thus, our protocol highlights appropriate, possibly appropriate, and inappropriate indications for IUC placement, with an emphasis on trying alternative modes of urine collection, communicating among healthcare providers regarding the necessity of an IUC, and reassessment of the patient for IUC removal.

 

Our protocols have yielded early promising results, but further research is underway to determine their specific impact. The goal is to create a protocol that is feasible and effective for the specific institution and department to which it is applied. By ensuring all members of the healthcare team are involved in the development and design of a protocol, there is ownership of its implementation and use, with the overarching goal of improving patient care.

Geriatric ED Guidelines
In the beginning of 2014, new consensus-based Geriatric Emergency Department (GED) guidelines were published in order to “provide a standardized set of guidelines that can effectively improve the care of the geriatric population and are feasible to implement in the ED.”¹² These guidelines are the result of a 2-year effort by representatives from ACEP, the American Geriatrics Society, the Society of Academic Emergency Medicine, and the Emergency Nurses Association, who were committed to optimizing the emergency-care delivery model for geriatrics. The participants encompassed both academic and community providers and included clinicians and researchers. These guidelines were formulated based on an 80% consensus among the representatives and, when possible, validated using existing literature at the time.

The genesis of the GED guidelines was multifactorial. In addition to the formation and rapid growth of geriatric interest groups and sections within EM academic organizations over the last 14 years, as well as the development of geriatric core competencies for EM residents in training, the 2010 Census Data results sharply outlined the details of the rapidly growing population of older adults in the United States. This acted as an alarm highlighting the need for a structured document containing best practice recommendations from geriatric emergency healthcare providers, researchers, and advocates. “The subsequent increased need for healthcare for this burgeoning geriatric population represents an unprecedented and overwhelming challenge to the American healthcare system as a whole and to emergency departments specifically,” the authors of the GED guidelines noted.

In response to a growing national interest in geriatric ED patients and an ever-increasing competition to attract patients from this demographic by EDs across the country, there has been a surge of self-designated GEDs during the last few years. Currently, more than 70 hospitals claim to have GEDs, raising the question of what sort of geriatric patient care is actually being delivered in these EDs. The question is of increased importance because very few of these “GEDs” are in academic centers or are associated with thought leaders in EM. In fact, when 30 self-designated GEDs that were snowball sampled in 2013 by researchers who asked what specific changes they had made toward the goal of improving care for the elderly, several rescinded this self-designation.

Because of heightened concerns for the needs of the increasing geriatric population overall, and the rise in the proportion of ED visits by this demographic, the authors of the GED guidelines state that “the contemporary emergency medicine management model may not be adequate for geriatric adults,” and offer the new GED guidelines as a basis on which EDs can consider ways to improve care for older adults while addressing the unique needs of this population. The GED guidelines propose specific methods and processes by which ED care of the elderly can be optimized. The authors note that “similar programs designed for other age groups (pediatrics) or directed towards specific diseases (STEMI, stroke, and trauma) have improved the care both in individual EDs and system-wide, resulting in better, more cost-effective care and ultimately better patient outcomes.”

The GED guidelines consist of 40 specific recommendations in six general categories: (1) staffing/administration; (2) equipment/supplies; (3) education; (4) policies/procedures/protocols; (5) follow-up/transitions of care; and (6) quality-improvement measures. This template outlines how to construct an effective GED program. The following highlights recommendations for each of these categories:

Staffing/Administration. Set qualifications and responsibilities for the medical director, nurse manager, staff physicians, nurses, and specialists, as well as accessibility to specialist ancillary services, with the goal of establishing hospital site-specific staff and coordination of local resources.

Equipment/Supplies. Develop potential physical and structural enhancements that address issues of mobility, comfort, safety, and behavioral needs (including memory cues and sensorial perception) while decreasing iatrogenic complications, such as the development of pressure ulcers (eg, the use of reclining chairs and pressure-redistributing foam mattresses).

Education. Provide nurse and clinical provider education and specialty-specific training focusing on contemporary, research-based geriatric-specific material, with regular assessment for interdisciplinary core competencies.

Policies/Procedures/Protocols. Implement a directed, comprehensive approach to facilitate screening and assessment of geriatric patients for added needs/post-ED adverse outcomes, as well as validated, ED-feasible screening tools/instruments for delirium and dementia, medication management, falls, use of urinary catheters, and the provision of palliative care.

 

Follow-up/Transitions of Care. Design discharge processes best suited for older patients (eg, large-font instructions), as well as collaborate with community resources to provide home-health services and home safety assessment in order to facilitate care following discharge.

Quality Improvement. Implement a system to collect and monitor pertinent and prevalent geriatric emergency care indicators (eg, incidence of injurious falls and documentation of fall risk assessment) designed to increase staff education and program success.

The authors clearly state that the GED guidelines represent recommendations. They are not a mandate for every ED, nor are they a list that requires 100% compliance. Instead, the document provides the potential steps to be taken, the rationale for these recommendations, and an outline of the resources available to aid in the transition from theory to implementation in any ED. The goal is to ensure better, safer, and age-appropriate treatment. In summary, these guidelines represent an effort to improve and even transform emergency care for older adults on the brink of one of the most significant challenges facing our healthcare system both in and beyond the ED.

Moving forward, the authors of the GED guidelines have defined a plan that “includes dissemination, implementation, adaptation, and refinement.” In addition to approval by each of the organization’s board of directors and the copyright of the material in 2013, the ED guidelines have now been widely disseminated through publication in numerous news articles (including international publications) and discussions on satellite radio. Tracking of new GEDs is planned. In addition, the prioritization of the guidelines is underway using a modified Delphi method, with the express purpose of assessing the relative potential benefits and harms associated with each recommendation by providing a weighted list from most important to least important.

A “Geriatric Emergency Department Boot Camp” is being developed to bring the recommendations to hospitals interested in “geriatricizing” their EDs. Geriatric EM leaders will act as consultants, providing training and a toolbox of resources. Specific reviews and revisions of the GED guidelines will take place in a 4- to 5-year cycle. Clearly, a next important step is the development of a GED certification system based on outcome studies of the individual components.

Criticisms of the GED guidelines have already been voiced among some EM providers. Specific concerns include a fear of partitioning the ED (as has occurred with pediatrics); an increase in cost and decreased efficiency; the need to maintain general expertise among EM physicians; the lack of evidence-based data upon which the recommendations were made; the fact that some guidelines were extrapolated from other clinical settings; and the belief that these changes will be too logistically difficult and take too much time.

The fact remains that the wave of geriatric patients (the “silver tsunami”) is already beginning to hit the shores of our hospitals. And GEDs are already here to help absorb the impact. The lack of iron-clad evidence for many of the recommendations should not be an absolute obstacle, but rather part of the natural evolution and improvement of similar endeavors. Nor should GEDs contain empty beds while younger adults sit in the waiting room, or conversely, force the elderly to wait for space in the GED when there are empty beds in the main ED. Ideally, the GED should be the location where the ED staff can implement these guidelines, which they can afterwards utilize in any part of the ED. These guidelines are designed to provide the best available expert opinion on how to deliver better geriatric care in the ED. The imperative for this goal is clear and necessitates this educated “leap-of-faith.” Change is never easy and often comes with an upfront cost of time, resources, and money. Moreover, there is nothing in a well-designed GED that may not also benefit, or at least will not adversely affect care of a younger adult as well. Therefore, flexibility and optimal utilization of space in a busy ED need not be sacrificed.

Conclusion

To improve diagnostic evaluation and care of the increasing number of geriatric patients presenting to the ED, reliable tools, protocols, and guidelines must be developed and implemented to ensure diagnostic accuracy, decrease adverse events, and improve patient outcomes. Fortunately, the new GED consensus guidelines are flexible and do not need to be wholly embraced—lending themselves to modifications and institution-specific adoptions. The “protocolization” and implementation of the guidelines may improve patient flow, operational efficiency, and, most importantly, the quality of care delivered. And likely, these guidelines will provide the foundation for future education and research into the improved emergency care of older adults.

 

The GED guidelines can be accessed at http://www.saem.org/docs/education/geri_ed_guidelines_final.pdf?sfvrsn=2.

Dr Stern is an assistant professor of medicine and codirector, geriatric emergency medicine fellowship, department of emergency medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York; and an assistant attending physician, department of emergency medicine, New York-Presbyterian Hospital.
Dr Mulcare is an instructor of medicine and an assistant attending physician, department of emergency medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York. She is a former fellow of geriatric emergency medicine.

Case 1 

An 82-year-old man presented to the ED accompanied by his son, who stated that his father “had not been acting right” for the past 2 days. The patient was combative, yelling “Go away,” and was intermittently more confused than his baseline; he was also eating and drinking less than usual. He had a history of mild dementia, noninsulin-dependent diabetes, hypertension, and arthritis; there were no recent changes in his medication. The patient lived alone in an apartment across the hall from his son and had home healthcare aide 4 hours a day, 3 days a week. He was independent of activities of daily living (ADL), but needed help with shopping and cooking. 

At presentation, the patient’s vital signs were: temperature, afebrile; heart rate (HR), 94 beats/minute; blood pressure (BP), 146/92 mm hg; respiratory rate (RR), 22 breaths/minute. Oxygen (O₂) saturation was 96% on room air. A finger-stick glucose test was 103 mg/dL. He was hyperalert and agitated, and did not appear oriented to place or time. There were no focal neurological deficits; mucous membranes were mildly dry; and faint crackles were heard at the right base of the lungs. The patient was placed on a monitor in a curtained room in the ED, and was given 2 L O2 via nasal cannula, which improved O2 saturation to 99%. With his son present, an intravenous (IV) line was placed and blood was drawn. An electrocardiogram (ECG) showed a sinus rhythm without ischemic findings.

During evaluation, the patient continued to pull at the monitor lines and attempted to get off the stretcher. To calm his agitation, he was given haloperidol 2.5 mg and lorazepam 1 mg; 10 minutes after administration, he became sedated and difficult to arouse. His vital signs remained stable.

Laboratory analysis revealed a white blood cell count (WBC) of 12.5 K/uL, a negative troponin, a brain natriuretic peptide (BNP) of 80 pg/mL, and normal blood urea nitrogen (BUN) and creatinine levels. Urinalysis was negative for infection, but chest X-ray showed a right lower lobe infiltrate. Blood cultures were drawn, and the patient was continued on maintenance fluids and started on IV antibiotics to cover community-acquired pneumonia. He was admitted to the hospital for pneumonia and altered mental status.

As the patient’s sedative state was followed by periods of agitation, he was treated with additional haloperidol and lorazepam by the inpatient medical team, which resulted in further sedation. On hospital day 3, his urinary output decreased. He was given an IV bolus of 3 L normal saline over 6 hours, after which his mental status began to improve, and he was switched to oral antibiotics. His mental status returned to baseline and O₂ saturation was 99% on room air. He was discharged home on hospital day 5 accompanied by his son.

Case 2

A 75-year-old man was brought to the ED with a 3-day history of worsening dyspnea on exertion, increased orthopnea, and increased bilateral lower extremity edema. He had a history of congestive heart failure (CHF), with an ejection fraction of 40%, and had been on 40 mg of furosemide daily at home; there were no recent changes to his medication. The patient was independent of ADL at baseline, living with his wife in a home with stairs. 

His vital signs at presentation were: temperature, afebrile; HR, 86 beats/minute; BP, 160/90 mm hg; RR 30 breaths/minute; O₂ saturation was 92% on room air. The patient had increased work of breathing and was speaking in four- to five-word sentences. Pulmonary examination revealed crackles half way up bilaterally. He also had 2+ pitting edema bilaterally in his lower extremities. He was otherwise alert and oriented.  

On 4 L O₂ via nasal cannula, the patient’s O₂ saturation was 98%.  Laboratory analysis revealed a BNP of 600 pg/mL, negative troponin, and normal creatinine level. Urinalysis was negative for evidence of infection. An ECG showed no changes, and chest X-ray revealed mild pulmonary congestion without an infiltrate. In the ED, an indwelling urinary catheter (IUC) was placed to monitor urinary output before the patient was given 40 mg of IV furosemide for diuresis. The patient was then admitted for management of exacerbation of CHF. As the medical team was preparing to discharge him on hospital day 2, his wife noticed that he was confused and not acting “like himself.” An investigation for causes of delirium included evaluation for infectious disease, which revealed an elevated WBC of 14.0 K/uL, stable creatinine; and urinalysis positive for bacteria, WBCs, leukocyte esterase, and nitrites. Since chest X-ray showed resolution of the vascular congestion, the patient no longer required supplemental O₂.

 

The IUC was removed, and the patient was started on IV antibiotics for a urinary tract infection (UTI) secondary to IUC placement. The inpatient stay was prolonged for an additional 3 days until his delirium cleared and he could be continued on oral antibiotics as an outpatient.

Discussion

There is nothing extraordinary about these two cases. Every day elderly adults present to EDs throughout the country with confusion caused by pneumonia and dehydration that is sometimes initially attributed to worsening dementia and then complicated or prolonged by overuse of powerful sedating medications. Also, complications resulting from IUCs inserted in the ED all too often prolong hospitalizations. But by using protocols designed for better, more efficient emergency care of elderly patients, their ED care can be substantially improved and any subsequent inpatient care shortened.

The older adult population (ages 65 years and older) often presents to the ED with similar complaints to their younger counterparts—eg, chest pain, abdominal pain, dyspnea. However, the history, physical examination, and social assessment of elderly patients usually lead to a more comprehensive work-up, as older adults tend to present in an atypical fashion for both illness and trauma, thus necessitating a broader differential. In addition, they are more susceptible to adverse reactions from medications and procedures.

Regardless of the ultimate diagnosis, simply presenting to an ED as a patient (and sometimes spending many hours there) places older adults at elevated risk of morbidity and mortality. The challenge is to develop reliable tools to streamline the management of this population in order to increase diagnostic accuracy, decrease adverse events, and improve patient outcomes.

Clinical Protocols
Clinical protocols are one way in which we can educate and standardize the practice of multiple levels of provider, including nurses, midlevel providers, and physicians. Adopting protocols is natural for EPs—the key is to make sure the clinical protocol to be implemented is designed or modified for the ED setting in which it will be implemented.

In our ED, we have recently implemented the following two protocols for common scenarios in older adults: (1) assessment and management of delirium; and (2) decreased use of IUCs. These protocols employ the following stepwise project plan:

1. Focus groups involving nurses, midlevels, residents, and attendings to assess ED provider knowledge, attitudes, and practice patterns regarding the clinical issue  in older adult patients, and to guide development of the clinical protocol by understanding needs and constraints of the current ED environment;
2. An extensive literature review of the clinical topic;
3. Development of the clinical protocol by the workgroup;
4. Implementation of protocol after multiple educational sessions using a scripted slide presentation to ensure all providers receive the same information; and
5. Subsequent data analysis from the electronic medical record to assess the impact (ie, outcome) of the protocol.

Delirium
Delirium is a common syndrome in older adults, but is often unrecognized despite its clinical importance. Although 7% to 17% of older adults who present to the ED suffer from delirium,^1-6 emergency physicians (EPs) miss 64% to 83% of cases, and 12% to 38% of patients with unrecognized delirium are actually discharged from the ED.^1,6-8 Unfortunately, patients discharged from the ED with undetected delirium are three times more likely to die within 3 months than those whose delirium was recognized.

Life-threatening causes are more apt to be recognized early on in the ED. With this in mind, we developed a new, comprehensive, evidence-based protocol for recognition, diagnosis, management, and disposition of agitated delirium in older adults in the ED, with a focus on identifying and treating the commonly missed contributing causes: analgesia, bladder-urine retention, constipation, dehydration, environment, and medications.⁹

IUC Placement in the ED
The second protocol implemented at our institution is a new, evidence-based protocol for the placement, management, and reassessment of IUCs. As emphasized by the National American College of Emergency Physicians (ACEP) 2013 Choosing Wisely Campaign,¹⁰ inserting an IUC is a procedure that should be undertaken judiciously as it is associated with an elevated risk of infection, delirium, falls, and other adverse events. As of 2008, the Centers for Medicare and Medicaid Services no longer reimburses for hospital-acquired catheter-associated UTIs.¹¹

After conducting focus groups of our ED providers, we learned that IUCs are placed more frequently than needed—often for reasons of convenience—and are rarely reassessed or removed if the patient is admitted to the hospital. Thus, our protocol highlights appropriate, possibly appropriate, and inappropriate indications for IUC placement, with an emphasis on trying alternative modes of urine collection, communicating among healthcare providers regarding the necessity of an IUC, and reassessment of the patient for IUC removal.

 

Our protocols have yielded early promising results, but further research is underway to determine their specific impact. The goal is to create a protocol that is feasible and effective for the specific institution and department to which it is applied. By ensuring all members of the healthcare team are involved in the development and design of a protocol, there is ownership of its implementation and use, with the overarching goal of improving patient care.

Geriatric ED Guidelines
In the beginning of 2014, new consensus-based Geriatric Emergency Department (GED) guidelines were published in order to “provide a standardized set of guidelines that can effectively improve the care of the geriatric population and are feasible to implement in the ED.”¹² These guidelines are the result of a 2-year effort by representatives from ACEP, the American Geriatrics Society, the Society of Academic Emergency Medicine, and the Emergency Nurses Association, who were committed to optimizing the emergency-care delivery model for geriatrics. The participants encompassed both academic and community providers and included clinicians and researchers. These guidelines were formulated based on an 80% consensus among the representatives and, when possible, validated using existing literature at the time.

The genesis of the GED guidelines was multifactorial. In addition to the formation and rapid growth of geriatric interest groups and sections within EM academic organizations over the last 14 years, as well as the development of geriatric core competencies for EM residents in training, the 2010 Census Data results sharply outlined the details of the rapidly growing population of older adults in the United States. This acted as an alarm highlighting the need for a structured document containing best practice recommendations from geriatric emergency healthcare providers, researchers, and advocates. “The subsequent increased need for healthcare for this burgeoning geriatric population represents an unprecedented and overwhelming challenge to the American healthcare system as a whole and to emergency departments specifically,” the authors of the GED guidelines noted.

In response to a growing national interest in geriatric ED patients and an ever-increasing competition to attract patients from this demographic by EDs across the country, there has been a surge of self-designated GEDs during the last few years. Currently, more than 70 hospitals claim to have GEDs, raising the question of what sort of geriatric patient care is actually being delivered in these EDs. The question is of increased importance because very few of these “GEDs” are in academic centers or are associated with thought leaders in EM. In fact, when 30 self-designated GEDs that were snowball sampled in 2013 by researchers who asked what specific changes they had made toward the goal of improving care for the elderly, several rescinded this self-designation.

Because of heightened concerns for the needs of the increasing geriatric population overall, and the rise in the proportion of ED visits by this demographic, the authors of the GED guidelines state that “the contemporary emergency medicine management model may not be adequate for geriatric adults,” and offer the new GED guidelines as a basis on which EDs can consider ways to improve care for older adults while addressing the unique needs of this population. The GED guidelines propose specific methods and processes by which ED care of the elderly can be optimized. The authors note that “similar programs designed for other age groups (pediatrics) or directed towards specific diseases (STEMI, stroke, and trauma) have improved the care both in individual EDs and system-wide, resulting in better, more cost-effective care and ultimately better patient outcomes.”

The GED guidelines consist of 40 specific recommendations in six general categories: (1) staffing/administration; (2) equipment/supplies; (3) education; (4) policies/procedures/protocols; (5) follow-up/transitions of care; and (6) quality-improvement measures. This template outlines how to construct an effective GED program. The following highlights recommendations for each of these categories:

Staffing/Administration. Set qualifications and responsibilities for the medical director, nurse manager, staff physicians, nurses, and specialists, as well as accessibility to specialist ancillary services, with the goal of establishing hospital site-specific staff and coordination of local resources.

Equipment/Supplies. Develop potential physical and structural enhancements that address issues of mobility, comfort, safety, and behavioral needs (including memory cues and sensorial perception) while decreasing iatrogenic complications, such as the development of pressure ulcers (eg, the use of reclining chairs and pressure-redistributing foam mattresses).

Education. Provide nurse and clinical provider education and specialty-specific training focusing on contemporary, research-based geriatric-specific material, with regular assessment for interdisciplinary core competencies.

Policies/Procedures/Protocols. Implement a directed, comprehensive approach to facilitate screening and assessment of geriatric patients for added needs/post-ED adverse outcomes, as well as validated, ED-feasible screening tools/instruments for delirium and dementia, medication management, falls, use of urinary catheters, and the provision of palliative care.

 

Follow-up/Transitions of Care. Design discharge processes best suited for older patients (eg, large-font instructions), as well as collaborate with community resources to provide home-health services and home safety assessment in order to facilitate care following discharge.

Quality Improvement. Implement a system to collect and monitor pertinent and prevalent geriatric emergency care indicators (eg, incidence of injurious falls and documentation of fall risk assessment) designed to increase staff education and program success.

The authors clearly state that the GED guidelines represent recommendations. They are not a mandate for every ED, nor are they a list that requires 100% compliance. Instead, the document provides the potential steps to be taken, the rationale for these recommendations, and an outline of the resources available to aid in the transition from theory to implementation in any ED. The goal is to ensure better, safer, and age-appropriate treatment. In summary, these guidelines represent an effort to improve and even transform emergency care for older adults on the brink of one of the most significant challenges facing our healthcare system both in and beyond the ED.

Moving forward, the authors of the GED guidelines have defined a plan that “includes dissemination, implementation, adaptation, and refinement.” In addition to approval by each of the organization’s board of directors and the copyright of the material in 2013, the ED guidelines have now been widely disseminated through publication in numerous news articles (including international publications) and discussions on satellite radio. Tracking of new GEDs is planned. In addition, the prioritization of the guidelines is underway using a modified Delphi method, with the express purpose of assessing the relative potential benefits and harms associated with each recommendation by providing a weighted list from most important to least important.

A “Geriatric Emergency Department Boot Camp” is being developed to bring the recommendations to hospitals interested in “geriatricizing” their EDs. Geriatric EM leaders will act as consultants, providing training and a toolbox of resources. Specific reviews and revisions of the GED guidelines will take place in a 4- to 5-year cycle. Clearly, a next important step is the development of a GED certification system based on outcome studies of the individual components.

Criticisms of the GED guidelines have already been voiced among some EM providers. Specific concerns include a fear of partitioning the ED (as has occurred with pediatrics); an increase in cost and decreased efficiency; the need to maintain general expertise among EM physicians; the lack of evidence-based data upon which the recommendations were made; the fact that some guidelines were extrapolated from other clinical settings; and the belief that these changes will be too logistically difficult and take too much time.

The fact remains that the wave of geriatric patients (the “silver tsunami”) is already beginning to hit the shores of our hospitals. And GEDs are already here to help absorb the impact. The lack of iron-clad evidence for many of the recommendations should not be an absolute obstacle, but rather part of the natural evolution and improvement of similar endeavors. Nor should GEDs contain empty beds while younger adults sit in the waiting room, or conversely, force the elderly to wait for space in the GED when there are empty beds in the main ED. Ideally, the GED should be the location where the ED staff can implement these guidelines, which they can afterwards utilize in any part of the ED. These guidelines are designed to provide the best available expert opinion on how to deliver better geriatric care in the ED. The imperative for this goal is clear and necessitates this educated “leap-of-faith.” Change is never easy and often comes with an upfront cost of time, resources, and money. Moreover, there is nothing in a well-designed GED that may not also benefit, or at least will not adversely affect care of a younger adult as well. Therefore, flexibility and optimal utilization of space in a busy ED need not be sacrificed.

Conclusion

To improve diagnostic evaluation and care of the increasing number of geriatric patients presenting to the ED, reliable tools, protocols, and guidelines must be developed and implemented to ensure diagnostic accuracy, decrease adverse events, and improve patient outcomes. Fortunately, the new GED consensus guidelines are flexible and do not need to be wholly embraced—lending themselves to modifications and institution-specific adoptions. The “protocolization” and implementation of the guidelines may improve patient flow, operational efficiency, and, most importantly, the quality of care delivered. And likely, these guidelines will provide the foundation for future education and research into the improved emergency care of older adults.

 

The GED guidelines can be accessed at http://www.saem.org/docs/education/geri_ed_guidelines_final.pdf?sfvrsn=2.

Dr Stern is an assistant professor of medicine and codirector, geriatric emergency medicine fellowship, department of emergency medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York; and an assistant attending physician, department of emergency medicine, New York-Presbyterian Hospital.
Dr Mulcare is an instructor of medicine and an assistant attending physician, department of emergency medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York. She is a former fellow of geriatric emergency medicine.