Geriatric Emergency Department Guidelines
Brief History of Geriatric Emergency Department (GED) Guidelines:
Geriatric Emergency Medicine is “Born”
Lowell Gerson published one of the earliest manuscripts exploring the future impact of an aging America on the fledgling specialty of emergency medicine in 1982. Nearly a decade later, the John A. Hartford Foundation provided a grant that catalyzed formation of a Geriatric Task Force at the Society for Academic Emergency Medicine, a series of original research manuscripts in Annals of Emergency Medicine (Lowenstein 1986, Skiendzielewski 1986, Jones 1986), and a 1996 textbook edited by Art Sanders entitled “Emergency Care of the Elder Person” (Figure below from Hogan 2023). Around the country, early thought leaders like Larry Lewis and Doug Miller began to explore the ramifications of aging physiology with cognition and gait on general emergency department operational flow and diagnostic efficiency. Ula Hwang's paper "The geriatric emergency department" provides insight on structural and process of care modifications to address the special needs of older patients (http://pmid.us/17916122). Tess Hogan's 2023 paper explains the progress early Geriatric Emergency Medicine advocates have made to deliver adequate care for the aging population (https://institutionalrepository.aah.org/cgi/viewcontent.cgi?article=1044&context=jgem).
2008Geriatric EDs began appearing in the United States
In November 2008 Holy Cross Hospital Silver Springs Maryland opened the first self-identified GED in response to the poor care received by his own mother during an ED visit. EM physicians and nurses were trained in GEM, and a full-time geriatric social worker guided older patients’ care. The second GED opened under the leadership of Mark Rosenberg, at St. Joseph’s Hospital in Patterson New Jersey in April 2009. Patients were happy with the care, and favorable press releases increased older adult volumes. This led to the formation of a 20- bed GED continuous with the main ED. Soon geriatric protocols were applied to all older adults in the entire ED, and specialized staff moved to each bedside as needed. Guided by these successes, all manner of hospitals began to self-identify and market their EDs using terminology including silver emergency room, senior ED, geriatric-friendly ED, and others. These so-called senior EDs featured improvements that ranged from a box containing a hearing aid and reader glasses to an entire ED staffed with physical therapists, social workers, and geriatric-trained ED nurses.
2008GED Guidelines published and approved by ACEP, AGS, ENA, and SAEM
Recognizing the heterogeneity of quality and emergency care experience across emerging self-described “senior EDs” the American College of Emergency Physician’s (ACEP) Geriatric Section and Society for Academic Emergency Medicine (SAEM) Geriatric Emergency Medicine Interest Group (now Academy of Geriatric Emergency Medicine), convened a team of emergency physicians, nurses, and geriatricians in 2011 to create a more standardized approach to age-friendly emergency care. Consequently, in 2014, the GED Guidelines (GEDG) provided recommendations for institutions and departments seeking to establish geriatric emergency care improvements. The GEDG list 33 recommendations identifying best practices in older adult emergency care and were endorsed by the Board of Directors of SAEM, ACEP, American Geriatrics Society, and the Emergency Nurses Association in 2014 as well as the Canadian Association of Emergency Physicians, American Academy of Emergency Medicine, and American College of Osteopathic Emergency Physicians in the years that followed.
2013ACEP accredits EDS for Geriatrics
The GEDG recommendations were foundational for increasing the recognition of the unique needs of aging adults during times of emergency to a wider audience. The GEDG served to identify a group of best practices and corresponding quality metrics in emergency older adult care. This listing catalyzed and enabled care improvements throughout the country, resulted in enhanced older adult care service lines at hospitals nationwide, and enabled the formation of the Geriatric Emergency Department Collaborative (GEDC, see https://gedcollaborative.com/). GEDC innovators then developed the concept of a Geriatric Emergency Department Boot Camp (http://tinyurl.com/GeriBootCamp2015ACEPNow) to help individual hospital systems implement transdisciplinary and measurable geriatric care improvements in their EDs. The goal was to promote the dissemination and implementation of the GEDG by linking actionable guideline recommendations with individual hospital’s ongoing quality improvement efforts. The work funded by John A Hartford Foundation and the Mary and Gary West Foundation, served to ignite emergency older adult care improvements in initially dozens and eventually hundreds of EDs
2018Launch preparations to review 2013 GED Guidelines
In 2017, ACEP recognized the need to help regulate the confusing claims of improved older adult care for the public. In May 2018, ACEP launched The Geriatric Emergency Department Accreditation Program (GEDA, see https://www.acep.org/geda). GEDA provided explicit criteria to attain three tiers of accreditation and designated reviewers to confirm adherence to those criteria, mirroring the more familiar trauma center designations (http://www.acepnow.com/article/acep-accredits-geriatric-emergency-care-emergency-departments/). The first ACEP accredited GED was Ascension Columbia St Mary’s Hospital Ozaukee approved on November 5, 2018. ACEP has accredited over 500 GEDs worldwide by mid-2024 (http://tinyurl.com/GlobalGeriED2016 and https://www.healthaffairs.org/do/10.1377/hblog20170912.061810/full/).
2020Updating the Original 2014 Geriatric Emergency Department (GED) Guidelines
By 2020 AGEM and ACEP Geriatric Section leaders realized that the quantity and quality of geriatric research was increasing at a rapid pace with the timeliness and relevance of the original GED Guidelines recommendations becoming outdated. For example, Emergency Medicine Australasia published the “Acute Geriatrics” series which highlighted the known knowns of Geriatric Emergency Medicine health outcomes research as well as the known unknowns (https://onlinelibrary.wiley.com/page/journal/17426723/homepage/acute_geriatrics_series). In Europe, the Silver Book was published providing similar actionable recommendations for the acute care of older adults during times of emergency (https://www.bgs.org.uk/resources/resource-series/silver-book-ii). Multidisciplinary geriatric emergency care teams also published European Geriatric guidelines in 2022 (http://pmid.us/34738224). The science of clinical practice guideline development had also matured as SAEM introduced Guidelines for Reasonable and Appropriate Care in the Emergency Department (https://www.saem.org/publications/grace) adherent to the GRADE criteria that had become accepted as the standard for guideline development by hundreds of organizations worldwide. The penetration of GED guideline recommendations and the fidelity with which these recommendations were delivered at the bedside were also questioned (http://pmid.us/343389196). In addition, multiple models of GED care were emerging along with adaptable Implementation Science-based approaches by which to initiate, scale up, and sustain age-friendly emergency care (http://pmid.us/25773739 and http://pmid.us/31732374 and http://pmid.us/34580860 and http://pmid.us/36653961). Concurrently, some within emergency medicine began challenging the pragmaticism and cost-benefit tradeoffs of adherence to the GED Guidelines and GEDA accreditation (http://pmid.us/28645389 and http://pmid.us/32335974 and http://pmid.us/35277967 and http://pmid.us/33646311 and http://pmid.us/37435831).
As a consequence of these challenges to the 2014 GED guidelines, evolving GRADE approach to deriving clinical practice guidelines and emergence of geriatric emergency medicine internationally, about 50 individuals representing emergency medicine, geriatrics, physiotherapy, pharmacy, nursing, patients, and healthcare leadership began planning a GRADE-adherent update to the original guidelines with an international authorship group. The members of this large group split across six working subgroups focused on the most common geriatric syndromes managed in emergency care: dementia, delirium, falls, polypharmacy, frailty, and elder abuse. Each subgroup derived specific PICO questions (PICO = Patient, Intervention, Control, and Outcome) and then conducted and published systematic review/meta-analyses of direct evidence for each PICO question. Next, each subgroup developed GRADE Evidence to Decision Frameworks (http://pmid.us/34022076 and http://pmid.us/27365494) pertinent to their diagnostic, prognostic, or therapy PICO question and including indirect evidence (http://pmid.us/35349211) to transparently evaluate the strength of evidence for benefits versus harms, health equity, feasibility, costs, acceptability and values before concluding on the strength and direction of actionable recommendation(s) and anticipated implementation approaches. This process is illustrated in the figure below and this website provides links to the systematic reviews and subsequent GED Guideline 2.0 documents as they are published.
Shan W. Liu, MD, SD, is an associate professor of emergency medicine at Harvard Medical School, and the Geriatric Emergency Medicine Fellowship Director and attending physician at Massachusetts General Hospital.