To: Board of Directors
From: David P. John, MD, FACEP, Chair
Robert T. Fitzgerald, MD, FACEP, Report Author
Geriatric Emergency Medicine Section
Date: October 7, 2008
Subj: Report on Council Resolution 24(07) Baby Boomers
Post Office Box 619911 That the Board accept the report as submitted by the Geriatric Emergency Medicine
Dallas, Texas 75261-9911
1125 Executive Circle
Irving, Texas 75038-2522
972-580-2816 (FAX) As a result of the Council Resolution 24(07) Baby Boomers, the Board charged the
Geriatric Emergency Section to report on the impact of the geriatric population on the
BOARD OF DIRECTORS nations emergency departments.
Linda L. Lawrence, MD, FACEP
Nicholas J. Jouriles, MD, FACEP Resolution 24 Baby Boomers
Brian F. Keaton, MD, FACEP RESOLVED, That ACEP study the impact of the baby boomer generation on our
Chair of the Board
Immediate Past President
nation’s Emergency Departments; and be it further
Angela F. Gardner, MD, FACEP RESOLVED, That a report of this study be made to the 2008 Council.
Sandra M. Schneider, MD, FACEP
Secretary-Treasurer Action: Assigned to the Geriatric Section to provide a recommendation to the Board.
Andrew I. Bern, MD, FACEP
Kathleen M. Cowling, DO, MS, FACEP Leaders of the section are in the process of developing a report for review by the Board
Ramon W. Johnson, MD, FACEP
Alexander M. Rosenau, DO, FACEP
by October 2008. The report will be provided to the Council after it is approved by the
Andrew E. Sama, MD, FACEP Board.
David C. Seaberg, MD, CPE, FACEP
David P. Sklar, MD, FACEP
Robert C. Solomon, MD, FACEP Through review of numerous articles and reports on this topic Robert T. Fitzgerald, MD,
FACEP assumed responsibility for the development of the report.
Bruce A. MacLeod, MD, FACEP
Speaker The report highlights the increasing demands that will be placed on emergency
Arlo F. Weltge, MD, MPH, FACEP
departments and emergency medicine, the changing of the paradigm of care in the
emergency department, financial imperatives, a new model of geriatric care in the
Dean Wilkerson, JD, MBA, CAE emergency department, and the role ACEP can play in this arena.
Prior Board Action
The Future of Geriatric Care in our Nation's Emergency
Departments: Impact and Implications
The Future of Geriatric Care in Our Nation’s Emergency Departments:
Impact and Implications
Emergency medicine, like all of healthcare, is facing a “perfect storm” of challenges in the next twenty years:
Increasing patient demand and expectations;
Increasing regulations and unfunded mandates;
Decreasing reimbursements and rising practice expenses; and
Nursing and ancillary personnel shortages.
But the one challenge that will trump them all and is indeed the driver of many of them is the aging of the
More than 70-million baby boomers will become eligible for Medicare starting in 2011 with a corresponding
huge increase in healthcare demand. Emergency departments (EDs) will play a pivotal role because they are
at the interface between outpatient resources and inpatient care and have a significant effect on resource
utilization. Emergency medicine must be prepared to assume that critical role.
For the sake of simplicity this paper will define geriatric as patients >65 years based on two considerations.
Many of the issues discussed revolve around Medicare/CMS mandates and reimbursements. In addition,
many of the reports, population data and clinical studies use this age cut off in describing the elderly.
This paper will address the following areas of the future of geriatric care in the ED:
Increasing numbers and impact of the elderly
Medical and financial imperatives to change the present paradigm of care
Creation of a new model of geriatric care
The role of ACEP in effecting change.
I. The Impact of Geriatrics on Emergency Practice
Elderly patients will be coming to EDs in ever-increasing numbers based on the sheer weight of
demographics, the limitation of the primary care system, and changing utilization patterns.
In the year 2000 persons over age 65 represented 13.1% of the population or about 35 million
persons. By 2030 that number is projected to be over 70 million or 20% of the population. In
addition, the fastest growing subgroups are the “oldest old” – a 28% increase in those >75 years
while those >85 years are increasing at 3-4x the rate of younger cohorts. Even at present utilization
rates at least 25% of patients in the average E.D. will be geriatric based on population statistics
B. Limitations of Primary Care
Can the primary care system absorb the increasing healthcare demands of the elderly? There are
four mitigating factors that will drive geriatric patients to EDs for care:
1. Shrinking primary care physician pool as a function of population and demand:
There is projected to be a deficit of 25,000 gerontologists by 2030, and the picture is just
as bleak for family practice and internal medicine. Between 1997 and 2005 the number of
graduating family practice residents going into primary care decreased by 50% as a
combination of a loss of residency positions, failure to fill available slots, and graduates
choosing other career paths. In the last ten years the percentage of internal medicine
residents going into primary care fell from 54% to 22%. The distant future doesn’t look
much brighter. A recent survey of medical students indicated only 2% were considering
careers in primary care.
2. Lack of financial incentives for primary and preventive care:
Outpatient care of the elderly is cognitive, labor-intensive and time-consuming. Under
present CMS guidelines which pay physicians 25-31% less than private insurers, most
practices have experienced a 4-6% operating loss/year over the last 5 years. As a matter of
financial necessity, many primary care practices avoid elderly patients. No wonder a
survey of physicians in Washington state in 2006 found 65% saying they are not accepting
new Medicare patients.
3. The complexity of care:
Geriatric patients often have multiple chronic diseases compounded by significant social
issues. Managing their medical problems in the outpatient setting where limitations
imposed by issues of cognition, mobility, transportation and the availability of
subspecialists becomes challenging and often impossible. Hospital-based EDs which are
seen as medical one-stop-shopping become an attractive alternative for their primary care.
4. The ED as the most appropriate medical venue:
The medical complexity of this population, coupled with the high risk of significant acute
disease, often means than an acute care setting like the ED is the most appropriate medical
venue for their evaluation and treatment.
C. Changing Utilization Rates
ED utilization rates for geriatric patients have increased 26% between 1993-2003. Coupled with
the population increases in those >75 years and the limitations of the primary care system, these
rates are likely to increase even faster in the future resulting in an increasing burden of geriatric
care for EDs.
As a result of these three factors, the number of geriatric patients presenting to EDs is likely to increase
dramatically in the next 15-20 years. Presently they represent about 15% of all ED patients and even the most
conservative estimates see 28% by 2025. Many experts, however, feel the number will be at least one-third
of all patients nationwide and closer to 40% in rural and many suburban areas. Of course there are presently
many areas in Florida and Arizona and parts of the Northeast where these numbers exceed 60%.
Not only will their numbers increase but, once in the ED, geriatric patients will have a disproportionate
impact on resources. While they represent 15% of all patients they account for 43% of all admissions and
48% of those admitted to the ICU. Their length of stay is 20% longer on average and they use 50% more lab
and radiology services and are 400% more likely to require social services interventions. The increasing
numbers, acuity and complexity of these patients will have a huge impact on ED operations and will
complicate issues of overcrowding and caregiver stress and may contribute to poor outcomes.
II. Changing the ED Paradigm of Care
The present model of care is designed to best serve acutely ill and injured patients that require rapid
interventions and treatments and, in fact, does quite well as evidenced by improving outcomes and morbidity
and mortality statistics for most disease entities. However, this paradigm is ill-suited for the typical geriatric
ED patient with multiple co-morbidities and with enigmatic complaints that evolve over longer periods of
time. There are both medical and financial imperatives that will drive a new model of care.
A. Medical Imperatives
Compared with younger, severity-matched cohorts, elderly patients have poorer clinical outcomes
in the ED. This is manifested in a number of ways:
Delayed or missed diagnoses such as acute MI, sepsis, appendicitis, ischemic bowel,
pulmonary embolus, etc.
Unsuspected diagnoses such as delirium, depression, cognitive impairment, drug/alcohol
dependence, elder abuse, polypharmacy, etc.
Undertreatment – as exemplified by the low rates of PCI in acute MI, TPA for stroke, less
surgical interventions, and inadequate pain management.
Overtreatment – as exemplified by the high rates of foley catheterization and adverse drug
events with inappropriate medications, especially sedatives and hypnotics.
The reasons for these less than acceptable outcomes are multiple and begin with an educational
deficit. Numerous surveys confirm that geriatric-specific education and clinical exposure is
missing in most residency training programs and many (if not most) practicing emergency
physicians feel uncomfortable and burdened treating geriatric patients. Our nursing and EMS
colleagues often share this anxiety. Diagnoses are often delayed, missed, or unsuspected because
in this age group common disease often have atypical presentations and require a high index of
clinical suspicion based on extensive experience with the elderly. Often we do not have evidence-
based protocols and outcomes research to guide our care. Patients >75 years are not included in
many research protocols which also limits therapeutic decision-making.
But, most importantly, the present ED model of care does not allow caregivers the time or support
to provide optimal care. The rapid triage and care process is often “unable to elicit full
understanding of the patient” and the “full breadth of medical conditions, a long list of
medications, communication challenges and slowly evolving problems . . . all impair effective
understanding of the patient’s needs.” Clearly a new model of care needs to be developed to deal
with geriatric patients in the ED.
B. Financial Imperatives
Nobody has a crystal ball to tell exactly what Medicare reimbursements will be in the future; but,
if recent history is any indication, it is clear that emergency services will not be compensated
commensurate with the expenses and resources involved. This has implications for the ED and
In areas with a high proportion of Medicare patients, such as many rural parts of the country, ED
physician staffing at individual hospitals and the geographic distribution of doctors in general will
become more problematic. Even in areas with moderate percentages of geriatric patients in the ED,
falling revenues will strain physician-patient ratios.
The financial impact of geriatrics will extend far beyond the walls of the ED and will dramatically
affect the dynamic of patient management. EDs are the hospital’s biggest admitters of Medicare
patients representing 57% of all admissions nationally. Of that number almost 70% are patients
with a medical (as opposed to surgical) diagnosis at discharge which has a negative impact on the
hospital’s bottom line with today’s CMS reimbursement guidelines. In a 2004 study Premera Blue
Cross of Washington State demonstrated that hospitals lost 16.4% on all Medicare admissions, a
number that is reflective of the national experience. And the future looks even less promising. The
Budget Reconciliation Act of 2005 mandated spending limits that are built in to reimbursements
regardless of demand. The President’s 2009 Budget in following these guidelines has proposed a
$15 billion dollar reduction in hospital payments over the next five years. The Health Advisory
Board in a 2002 study accurately predicted the future when it projected a 12% revenue decline per
patient-day by 2010 and cited as two principle reasons the aging of the population and rising ED
admissions. Add to this the recent implementation of non-reimbursements for “never happen”
events and CMS’ cutting payments for previously lucrative procedures such as pacer-defibrillation
and joint replacements and the financial picture gets even worse for hospitals.
What is the implication of these financial realities on EM practice? There will of necessity be
increasing pressures on EDs to act as more stringent gatekeepers for Medicare admissions,
especially for those with vague medical complaints (the “soft” admissions). The era of a low
threshold for admissions for the elderly will become a thing of the past. EDs will be expected to do
more extensive evaluations, observe patients longer, seek more consultations, and explore
outpatient alternatives. In this new gatekeeper role, EDs will become to a much greater extent
observation units for geriatric patients to prevent questionable hospital admission.
III. A New Model of ED Geriatric Care
Because of the impact of geriatrics on EM practices and the medical and financial imperatives to improve
outcomes, a new paradigm of care is needed. Because of the magnitude of this impact and the serious
consequences of failing to respond appropriately, there has to be a man-on-the-moon-this-decade urgency to
accomplishing this change. Organized emergency medicine has responded to such challenges in the past as
exemplified by the improvements in pediatric and trauma care.
This new model of care encompasses
A. Infrastructure (Fig. 1)
EDUCATION (Acute Care)
+ Clinical Pathways
CLINICAL (Extended Care)
RESEARCH Quality Measures
The foundation of improvement rests on the dual pillars of education and clinical research.
Until recently there has been a notable absence of geriatric-specific training in EM residency
programs as evidenced by multiple surveys indicating trepidation in treating the elderly. A core
curriculum needs to be developed and enhanced coupled with adequate clinical exposure to bridge
this knowledge and comfort gap.
Educational modules reflecting a core of geriatric knowledge must be developed and disseminated
to front line caregivers and include physicians, nurses, ancillary personnel and EMS. Present
efforts need to be elaborated and updated so that this core of knowledge gets to the bedside in
much of the same way that acute pediatric and trauma concepts have permeated daily practice.
The second pillar is clinical research with a special emphasis on risk stratification, prevention,
disposition and outcomes that also includes the community hospital setting. This is a complex
patient group and presently evidence is often lacking to guide the clinician’s clinical practice and
decision-making. Older patients need to be included in acute care research protocols so that risks
and benefits can be judged accurately.
Besides raising the general level of knowledge about geriatrics, education and research should lead
to at least three useful tools:
Clinical protocols (acute treatment)
Clinical pathways (extended treatment)
Evidence-based data will allow EM practitioners to effectively guide the acute evaluation and
treatment phase in the ED and to integrate that care in the appropriate medical setting through use
of the pathways. As our knowledge base expands and outcomes can be more systematically
evaluated, quality measures that are evidence-based, rational, relevant and doable can be
developed to guide improvement efforts.
B. Integration (Fig. 2)
The ED plays a pivotal role in geriatric care as the critical interface between hospital services and
outpatient resources. The pathways should be a tool to guide the patient under the direction of the
EM physician seamlessly through the system to the most appropriate clinical setting(s) and may
include a period of observation before disposition. On the inpatient side of the equation, the ED
evaluation and treatment should compliment and expedite the hospital care to minimize length of
stay and maximize outcomes. On the outpatient side, the ED should be closely linked with all
available resources pertinent to discharge including the ability to communicate data effectively and
to ensure appropriate follow-up care.
C. Implementation (Fig. 3)
GERIATRIC ED TEAM Social Services
GERIATRIC ED DESIGN Rooms/space
MACRO Obs Unit
To operationalize this focused geriatric care, changes need to be made in both the staffing model
and department design. The complexities of these patients demand more time and attention than
can be given in the typical acute care setting by the doctor-nurse-tech staffing model. A geriatric
care team concept needs to be utilized that would include a social worker/care manager, and a
geriatric mid-level provider, supplemented by a pharmacist, OT/PT, pastoral care, etc., as needed.
The ED physician and nurse need to address acute medical problems but the rest of the team will
often be necessary to gather all relevant clinical information, address important but not acute
medical issues, to evaluate all disposition options, and to screen for other conditions that may
In order to support this new paradigm of care changes need to be made in ED design and consist of
both macro and micro elements. The macro changes recognize that bed number estimates may
have to be revised to reflect longer lengths of stay. Adjacencies for diagnostic studies and
treatments need to be incorporated into overall hospital design as well as accommodations for
increased numbers of caregivers and consultants within the ED. Observation areas either in the
hospital or the ED may have to be designed to allow appropriate evaluations. Micro changes are
geared to make the ED more geriatric-friendly and include modifications to address the bright,
loud, chaotic and uncomfortable environment seen in most EDs today. These changes would
include quiet, private rooms with thick mattresses and softer lighting schemes in close proximity to
caregivers with adequate space for in-room family and visitors among other things.
IV. The Role of ACEP – Next Steps
There are many generic things ACEP is presently doing and should continue to do to improve the overall
environment for ED geriatric care. On the political front, ACEP should continue to advocate with CMS and
our congressional representatives for adequate reimbursements for the care provided to Medicare patients in
the ED to ensure that resources will be available to care for their increasing numbers. ACEP should continue
to be the leader in coordinating the expertise and resources of our colleagues in organizations dealing with
geriatrics to focus efforts to improve care.
In addition to these general approaches there are specific measures where ACEP can expedite this new model
Prioritize and provide support for the development of an enhanced geriatric core curriculum
for resident training.
Prioritize and support the development and dissemination of a body of core knowledge for
practicing emergency clinicians similar to that for pediatrics and trauma.
Prioritize and support clinical research projects especially emphasizing risk stratification,
prevention, outcomes and disposition involving the community hospital setting.
3. Clinical Management Tools
Prioritize and support the development of clinical protocols, clinical pathways and quality
measures that are evidence-based and are geared to providing a road map for safe, cost-
4. Demonstration Projects
Support and fund demonstration projects that implement and evaluate aspects of this new
model of care, especially the utilization of a geriatric ED team, alternative outpatient care
models, links with inpatient/observation systems, and new ED design elements.
Baby boomers are going to hit the healthcare system like a tsunami in the next 20 years resulting in a marked
increase in geriatric ED patients beginning in the next 5 years. Our present paradigm of care and ED design
are ill-equipped to address the health needs of these patients, and there are pressing medical and financial
imperatives to change. ACEP needs to be the leading force in developing a new model of care to provide
appropriate, safe, cost-effective care to the elderly.
Robert T. Fitzgerald, MD, FACEP
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