Urgent care, acute care, emergency care: understanding GEM and its issues

exterior shot of gem facilitiesFor a topic that attracts so much interest from policy-makers, commissioners, providers and society at large, it is surprisingly difficult to find a single, clear definition of urgent care. Most commonly it is used to refer to the process of seeking unplanned (non-elective) care from the ambulance service, in emergency departments, or in general practices or urgent care centres. ‘Urgent and emergency health needs are those that the patient perceives require a response on the same day that they arise. The judgement of urgent and emergency is made by the patient and not by the clinician.’

Developing systems and processes to improve outcomes for older people with urgent care needs has been described as a ‘wicked problem’. This reflects the clinical complexity but also the difficulties organising services that are best suited to meet patients’ needs.

Organisational issues

The Emergency Department (ED)

The ED is a key component of the health and social care system, responsible for the initial assessment, which strongly influences the subsequent management, and determining ‘disposition’. Traditional emergency medicine facilities, staff training, and behaviours have tended to focus upon clinically-urgent scenarios, creating a potential mismatch between the emergency department response and the nature of the population that they are increasingly facing.

Predominantly in North America, there has been some enthusiasm for ‘elder friendly emergency departments’ – separate EDs dedicated to the care of older people. These separate elder friendly EDs have not been evaluated using a whole systems framework, although there is guidance on ‘what good looks like’1-6

Whilst their impact of outcomes is uncertain, but it is hard to imagine that duplicating EDs for such a large and growing population will be feasible or sustainable in the long term. Others have responded with a range of design orientated or education and training initiatives to enhance emergency department teams’ capacity and competence to respond to the needs of older people.

Finally, a range of service initiatives have been evaluated (predominantly from the service perspective), that embed geriatric teams in the ED context, delivering both direct clinical care in addition to ‘standard’ ED services, and also supporting ED staff through education, training and role modelling. Whilst some of these evaluations appear to show promise, the overall evidence is limited2, 3, 7-12.

The Acute Medical Unit

Reflecting the situation in the ED, acute medical units are also seeing a growing population of older patients with increasing frailty as part of their daily routine. Whilst acute physicians are well-trained in acute medical care, and have a more in-depth understanding of medicine than their ED counterparts (whose training encompasses a wide range of specialities other than medicine), there has not traditionally been a great focus on geriatric competencies. 

However, this is changing, and in the UK at least, trainees in acute medicine have between 5-10% of their training dedicated to geriatric medicine, alongside frequent daily exposure to the care of older people with frailty in their clinical practice.

Yet even in the United Kingdom, where acute medical units were first initiated and the specialty of acute medicine is well-established, outcomes for older people attending and then being discharged from acute medical units remain poor: in one series 76% had one or more adverse outcomes (death institutionalisation, readmission, increase in dependency or decline in mental well-being or quality of life) over the three months following discharge from an acute medical unit13, 14.

In the acute medical unit context, there is evidence that frailty units that attempt to deliver CGA can improve patient outcomes although many of the trials are from outside of Europe and many are now quite dated. 

However, more recent controlled evaluations appear to support the findings in the RCT literature, as does national guidance such as the Silver Book and the Royal College of Physicians’ Acute Care Toolkit. Yet provision is variable as evidenced by the 2016 NHS benchmarking report15 on urgent care for older people– less than half of hospitals surveyed offered some form of specific frailty care in the first 72 hours of an older person’s acute hospital stay. This has led to the development of large scale quality improvement projects to try and address the ‘know-do-gap’16.

Clinical issues

Older people often typically present atypically – that is to say that the classic textbook features of a given condition may not be present. These atypical or non-specific presentations are usually related to complex interactions between multiple comorbidities (for example, osteoarthritis related pain preventing the development of heart failure associated exertional dyspnoea), cognitive impairment (reduced ability to communicate or in the case of delirium, reduced arousal or consciousness) and concomitant functional decline (making falls and immobility much more common in the face of apparently innocuous illness)17.


References

1. McCusker J, Verdon J, Vadeboncoeur A, Lévesque J-F, Sinha SK, Kim KY, et al. The Elder-Friendly Emergency Department Assessment Tool: Development of a Quality Assessment Tool for Emergency Department–Based Geriatric Care. Journal of the American Geriatrics Society. 2012;60(8):1534-9.

2. Wallis M, Marsden E, Taylor A, Craswell A, Broadbent M, Barnett A, et al. The Geriatric Emergency Department Intervention model of care: a pragmatic trial. BMC Geriatrics. 2018;18(1):297.

3. Stevens M, Hastings SN, Markland AD, Hwang U, Hung W, Vandenberg AE, et al. Enhancing Quality of Provider Practices for Older Adults in the Emergency Department (EQUiPPED). Journal of the American Geriatrics Society. 2017;65(7):1609-14.

4. Nickel C, Bellou A, Conroy S. Geriatric emergency medicine2017 2017/01/01/. 1-405 p.

5. Sanon M, Abraham G, Investigators TGW. Geriatric Emergency Department Innovations through Workforce, Informatics, and Structural Enhancements (GEDI WISE): an acute care for the elderly (ACE) model for elders in the ED. 2016;64:S67.

6. Carpenter CR, Bromley M, Caterino JM, Chun A, Gerson LW, Greenspan J, et al. Optimal Older Adult Emergency Care: Introducing Multidisciplinary Geriatric Emergency Department Guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine. Journal of the American Geriatrics Society. 2014:n/a-n/a.

7. Jay S, Whittaker P, Mcintosh J, Hadden N. Can consultant geriatrician led comprehensive geriatric assessment in the emergency department reduce hospital admission rates? A systematic review. Age and Ageing. 2016.

8. Milisen K, Devriendt E, Heeren P, Deschodt M, Sabbe M, Fieuws S, et al. Effectiveness of comprehensive geriatric assessment based interventions in the emergency department: a systematic review and meta-analysis. 2015. Available from: http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015029208.

9. Wright PN, Tan G, Iliffe S, Lee D. The impact of a new emergency admission avoidance system for older people on length of stay and same-day discharges. Age Ageing. 2014;43(1):116-21.

10. Aldeen AZ, Courtney DM, McCarthy DM, Dresden SM, Gravenor S. GEDI WISE: geriatric-specific assessment intervention in the emergency department is associated with differences between initial and final disposition. 2014;1:S233-S4.

11. Arendts G, Fitzhardinge S, Pronk K, Donaldson M, Hutton M, Nagree Y. The impact of early emergency department allied health intervention on admission rates in older people: a non-randomized clinical study. 2012;12:8.

12. Conroy SP, Ansari K, Williams M, Laithwaite E, Teasdale B, Dawson J. A controlled evaluation of comprehensive geriatric assessment in the emergency department: the ‘emergency frailty unit’. 2014;43:109-14.

13. Edmans J, Bradshaw L, Gladman JRF, Franklin M, Berdunov V, Elliott R, et al. The Identification of Seniors at Risk (ISAR) score to predict clinical outcomes and health service costs in older people discharged from UK acute medical units. Age and Ageing. 2013;42:747-53.

14. Wou F, Gladman JRF, Bradshaw L, Franklin M, Edmans J, Conroy SP. The predictive properties of frailty-rating scales in the acute medical unit. Age and Ageing. 2013;42:776-81.

15. network NB. Older people's care in acute settings Benchmarking Report [internet] accessible from https://static1.squarespace.com/static/58d8d0ffe4fcb5ad94cde63e/t/58fdcaecb3db2b703c519d06/1493027574961/OlderPeoplesCareinAcuteSettings2016SummaryReportMarch2017.pdf. 2016.

16. Gladman JRF, Conroy SP, Ranhoff AH, Gordon AL. New horizons in the implementation and research of comprehensive geriatric assessment: knowing, doing and the 'know-do' gap. AGE AND AGEING. 2016;45(2):194-200.

17. Limpawattana P, Phungoen P, Mitsungnern T, Laosuangkoon W, Tansangworn N. Atypical presentations of older adults at the emergency department and associated factors. Archives of Gerontology & Geriatrics. 2016;62:97-102.