System Spotlight: Cleveland Clinic

Heather Wojtarowicz

GEDC’s System Spotlight Series shares the great work that member organizations are doing in the field of geriatric emergency medicine.

Through the pursuit of GEDA accreditation, implementation of meaningful QI initiatives, and provision of educational resources for clinicians, health systems that take advantage of GEDC membership are setting the standard for outstanding geriatric emergency medicine.

Cleveland Clinic is one of the world’s largest healthcare systems. As of Dec. 2022, Cleveland Clinic boasted 23 hospitals, 265 outpatient facilities and more than 78,000 caregivers worldwide. Outside of its main campus in Cleveland, the health system comprises 15 regional hospitals in Northeast Ohio, five hospitals in Southeast Florida, a center for brain health in Las Vegas, executive health and sports health services at two locations in Toronto, Canada, one hospital in Abu Dhabi, and one hospital in London. In its Northeast Ohio emergency departments alone, Cleveland Clinic reported 650,000 visits in 2023, and 173,000 of those visits were for older adult patients. All of Cleveland Clinic’s Northeast Ohio emergency departments hold at least Level 3 GEDA accreditation.

Throughout the world, Cleveland Clinic is recognized for healthcare innovation, and in 2018, the system recognized the need for that signature innovation in the field of geriatric emergency medicine.

“We always had a good presence of geriatric medicine in the hospital, but the alignment of the processes started to happen in 2018 when we all realized that we could do better in caring for older patients in the emergency room,” said Saket Saxena, MD, co-director of Cleveland Clinic’s Geriatric Emergency Department.

What resulted from Cleveland Clinic’s commitment to providing a high standard of care for older adult patients is a five-bed geriatric care unit (GCU) in its flagship hospital’s emergency department. The GCU launched in 2018 and is designated for low acuity, high complexity older adult patients who benefit from more comprehensive evaluation.

“We use the observation model because it’s an easy way to get the patients out of the busy ED into a quieter environment,” said Stephen Meldon, vice chair of the Emergency Services Institute at Cleveland Clinic. “It  allows us more time to do that evaluation and not worry so much about ED throughput and moving the patient along.”

Cleveland Clinic’s GCU is the result of the collaboration between Meldon and Saxena, a geriatrician in Cleveland Clinic’s Center for Geriatric Medicine who is embedded in the emergency department and provides care for older adult patients.

“The uniqueness of our program is that we’ve been able to integrate geriatric medicine services within the emergency room completely,” Saxena said. “You don’t just have the processes; you also have the intervention. What makes me more involved is my understanding of how the ER works for older patients and how we can work together with ER doctors in real time.”

Cleveland Clinic has also executed numerous quality improvement initiatives to improve the standard of care for older adults in emergency departments throughout the health system. In pursuit of GEDA accreditation for all its emergency departments, Cleveland Clinic started a system-wide delirium screening program to improve its delirium detection rate.

A key component of the system’s delirium screening program is an electronic medical record-based algorithm that identifies patients who are at an increased risk of delirium and prompts triage nurses to complete the screening. Factors that contribute to the algorithm include patient age, polypharmacy, fall complaints, documented dementia history, and high ED utilization.

The algorithm has helped clinicians effectively detect delirium in thousands of patients, which Saxena said is not always easy to do in a busy emergency department.

Cleveland Clinic has added other enhancements to EPIC, its electronic medical records system, to prompt clinicians with screening protocols and alerts based on patient information. For example, EPIC has built-in alerts for potentially inappropriate medications (PIMs). When a provider orders a medication that is not ideal for a medically complex older adult patient, that provider is prompted with an order set that suggests an alternative medication and takes the provider to the new order.

“We’re actually automating and making it safer to prescribe medications with the select list of potentially inappropriate medications,” Meldon said. “I think that’s one way to drive standardized care and quality.”

Establishing system-wide standards of care has been the cornerstone of Cleveland Clinic’s efforts to innovate and implement better care processes for older adults in the emergency department since beginning the work in 2018. From its outset, the system has relied on a core content team of experts in geriatrics, pharmacy, emergency medicine, case management, physical therapy, social work and data analytics to ensure continuity throughout the system. The system holds a quarterly regional meeting for all geriatric ED champions to review the latest care practices and protocols.

Cleveland Clinic is also a member of the GEDC. According to Meldon, the collaboration afforded by GEDC membership has allowed Cleveland Clinic to share best practices and learn from other health systems as it continues to innovate in the realm of geriatric emergency care.

“Innovation is part of Cleveland Clinic’s DNA, and that’s why I love working here,” Meldon said. “That is driving a lot of our work to take care of these patients.”

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