Providing food and drink in the emergency department (ED) is a fundamental aspect to care and comfort for those who are in need. Access to food and drink can re-engage the patient and family in a normal interaction in the context of their emergency. When our health system sought to understand the process to access food in the ED and improve our care, we found very limited guidance in the medical literature. This paper will describe the background to providing nutrition for older patients in the emergency department, a systems-based approach to providing a meal, and finally clinically relevant tips to interacting with older adults during their meal.

The American College of Emergency Physicians (ACEP) Geriatric Emergency Department Accreditation (GEDA) Guidelines describe the need for easy access to food and drink at all times for older adults in the ED.¹ The intention of the GEDA guidelines is to highlight a basic need often not addressed during an extended period in the hurried ED environment. While seemingly straightforward, there are many barriers to providing meals for older patients in the ED. These include patient factors, such as disease-specific diets (e.g. diabetic or renal) and consistency modifications (e.g. pureed or mechanical soft). Facility barriers include difficulty providing food between scheduled mealtimes, inadequate staffing and/or training to obtain and assist with meals, and default NPO status for all patients.

As we prepared for GEDA accreditation across our large health system, we noted different strategies to best provide older adults with ED meals. Some sites stored meals in the ED refrigerator, while others called the hospital nursing supervisor to retrieve a meal from the hospital kitchen. While several papers have described nutrition screening for acutely ill older adults,^2,3 we could find no paper describing an approach to provide meals for those receiving emergency care. Most papers describe the nutritional assessment of older adults in the context of hospital care or long-term care.^4,5  We describe a standardized meal policy for older adults in the ED.

Our health system Food and Nutrition Services collaborated with the Geriatric Emergency Department leadership to implement a standardized senior-friendly boxed lunch.  Key components to the boxed lunch include: half a chicken salad sandwich on white bread, diced peaches, sugar free vanilla pudding, 2% milk, napkin, spoon, and straw (taken out as necessary) See figure. This cost is $1.90 as of August 8, 2020. The meal comes in a cardboard container with individually wrapped items. While the containers are easy to open, the nurse does set this up for our patients. The meal meets dietary requirements for those with co-morbid conditions of diabetes mellitus and cardiovascular disease. The meal does not, however, address specific allergies/ intolerance to wheat, gluten or dairy products. Additionally, the nurse assesses if the patient can or cannot have the straw. The straw is taken out for those who have difficulty swallowing. Most ED sites are provided three box lunches per day- based on the volume of patients. The un-used containers are replaced daily. While the boxed lunch was designed for older adults, it is available to ED patients of all ages. The nutrition leader helped to disseminate the program to five ED sites in Wisconsin. Each site described the process in their GEDA application. All five sites continue to use the program after certification and during the COVID-19 pandemic. We continue to disseminate this protocol to new health system sites seeking accreditation.

As an ED team develops a quality improvement program to provide meals, consider the needs of an ethnically and culturally diverse population. Further, many older individuals are vegetarian and others may be vegan. Provide alternatives to the uniform boxed lunch we describe, depending on the community your ED serves.

The Box below describes clinically relevant tips and systems- based strategies to providing nutrition for older adults in the ED. Similar to screening an older patient for gait & balance and delirium, interacting with an individual during a meal can provide important functional and social information.

Having a senior friendly boxed lunch eases the family’s stress, as it addresses a basic need during an already stressful time. It also provides the family comfort, knowing that their older adult family member’s specific nutritional needs are being met. This reassures our patients and their families that our care addresses the whole person.