Emergency Department Care of Older Adults During the Time of COVID-19
This article has been written in advance of a JGEM supplement. It presents relevant, practical information about the care of Older Adults in the ED during the COVID-19 pandemic.
When JGEM published “COVID-19 in Older Adults: Key Points for Emergency Department Providers” on March 21, 2020 there had been a total 116 deaths in the US from COVID-19. As of November 16, 2020, there are over 246,000 deaths in the US. Over 95 Percent of these deaths are in people age 50 or older. In just eight months we have witnessed a devastating increase in the impact of COVID. With new cases surging across the country many health care systems and hospitals are stretched beyond capacity.
Accordingly, GEDC is collaborating with national and international colleagues to develop best practices in the emergency treatment of older adults with SARS-CoV-2 and during the time of the COVID-19 pandemic. Here, we list a few key points with links containing more information and practical guidance.
Delirium is on the Rise
Acute confusion or delirium is a sign of physiological stress linked with increased morbidity and mortality in older adults. Older adults with COVID-19 frequently present with delirium. Additionally, many older adults without COVID-19 are at risk of delirium from increased lengths of ED stay and prolonged social isolation.
Screen for delirium, address isolation using in-person and/or tele-facilitated visits and basic needs such as food and pain control are met.
Palliative Care and Advance Care Planning
It is critical to ensure care aligns with patient wishes. Vital Talk has great resources to facilitate Advance Care Planning discussions. The Center to Advance Palliative Care has great tips to help connect your ED with palliative care resources. Finally, GEDC has put together best practices for building palliative care into the ED.
Telehealth and Forward Triage
Many patients fear contracting COVID-19 in the ED and are anxious about ED/hospital-imposed separation from their loved ones. Through the pandemic, we have developed unprecedented access to tele-triage and telehealth. Now many patients can be treated at home. Additionally, telehealth review ensures patients that present to the ED really need emergency care. The GEDC offers direction on how to launch a telehealth program during the COVID-19 pandemic.
Transitions of Care
A successful transition of patients in and out of the ED is key to providing safe care during this pandemic. GEDC offers tools for better coordination of care, reducing the risk of bounce backs and limiting adverse outcomes to ED exposure.
Caregivers Are Part of the Healthcare Team
Caregivers are NOT visitors.
While there is an understandable need to limit visitors during an infectious pandemic, for vulnerable older adults, especially for those with cognitive impairment, their caregivers are a critical part of the care team. Differentiating caregivers from visitors, and incorporating caregivers into the care team whenever possible, is critical to keeping vulnerable older adults safe during the pandemic.
Dr. Kevin Biese serves as an Associate Professor of Emergency Medicine (EM) and Internal Medicine, Vice-Chair of Academic Affairs, and Co-Director of the Division of Geriatrics Emergency Medicine at the University of North Carolina (UNC) at Chapel Hill School of Medicine as well as a consultant with West Health. With the support of the John A. Hartford and West Health Foundations, and alongside Dr. Ula Hwang, he serves as Co-PI of the national Geriatric Emergency Department Collaborative. He is grateful to chair the first Board of Governors for the ACEP Geriatric Emergency Department Accreditation Program. His passion is for improved education and systems of care for older adults, and he has published multiple materials in both these areas.
Dr. Teresita Hogan is an Associate Professor of Medicine and Director of Geriatric Emergency Medicine at the University of Chicago Medicine. Her clinical research interest are Geriatric EM, Quality Improvement, Emergency Pain Management, Emergency Management of Falls in Older Adults, and Models of Care. Dr. Hogan is the ACEP representative to the AGS and serves on the executive committee Section for Enhancing Geriatric Understanding and Expertise among Surgical and Medical Specialists. She is an expert in graduate medical education and led the expert consensus process to establish The Geriatric Competencies for Emergency Medicine Residents.
She has also worked on identifying the number and characteristics of geriatric emergency departments across the United States and is a member of the GEDA Board of Governors.
Dr. Michael Malone is the Medical Director of Aurora Health Care - Senior Services and the Aurora at Home. He is a Clinical Adjunct Professor of Medicine at the University of Wisconsin School of Medicine and Public Health. He also serves as the Director of the Geriatrics Fellowship Program at Aurora Health Care. Dr. Malone received his undergraduate and medical degrees from Texas Tech University in Lubbock, Texas; he completed his internal medicine residency and geriatric fellowship training at Mt. Sinai Medical Center in Milwaukee. His Aurora Health Care practice is to home-bound older persons in inner-city Milwaukee.