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S H O R T R E P O R T Open Access
Emergency Department presentation of
frail older people and interventions for
management: Geriatric Emergency
, Elizabeth Marsden
, Andrea Taylor
and Marianne Wallis
As population’s age and people live longer, the burden on acute health care services associated with the frail aged
increases. Recognising the needs of this cohort as well as designing and evaluating interventions to manage their
care in the emergency department has been reported in the literature. Transition to new models of care in
emergency departments (ED) focused on improving the care of older people can also assist in reducing length of
stay in the ED, reducing complications associated with ED presentation and prevent inappropriate hospitalisation.
The Geriatric Emergency Department Intervention (GEDI) aims to build on the successful components of other
models of care for older people in acute healthcare settings to improve safety and best meet the needs of both
older people and health service providers.
Keywords: Advanced practice nurse, Emergency department collaboration, Geriatric, Aged care, Hospital avoidance,
In the developed world, the proportion of the popula-
tions of people aged 65 years and over are increasing at
a disproportionate rate, compared to other age groups,
resulting in an increased burden on health systems as a
consequence of the chronic disease and frailty experi-
enced by this cohort . Emergency departments (ED)
are increasingly being accessed by older people from
both the community and residential aged care facilities
(RACF) to either meet shortfalls in access to primary care
or when usual primary care is disrupted [2, 3]. Reasons for
presentation to the ED by older people for low acuity con-
ditions are reported to be influenced by perceived ur-
gency, difficulty accessing primary healthcare, referral to
ED from Primary Healthcare Physician (PHP) [3, 4] and
staffing in RACFs [5–7]. The presence of chronic comor-
bidities such as chronic airways disease, congestive cardiac
failure, and diabetes in addition to other functional
considerations such as the presence of indwelling devices
and absence of an Advance Care Plan were reported as
risk factors for transfer to the ED .
Evidence of the efficacy of health service interventions
aimed at providing appropriate care for ageing popula-
tions is present in the literature with varying levels of
success reported [9–18]. Some examples of these inter-
ventions are: improving care in RACFs via change in
staffing models most often to include a Nurse Practi-
tioner , interventions in EDs for presentation of
older people, and outreach models from health services
to the community most often provided by nurses,
hospital in the home (HITH) and hospital in the nursing
home (HINH). Interventions within RACFs found to be
successful in improving care of residents include use of
gerontology specific clinical pathways, improved com-
munication with primary pracitioners and promotion of
Advance Care Planning (ACP) . Evidence for
successful, ED specific interventions in improving care
for older people who present to the ED, focuses on
supported discharge, senior medical review, comprehen-
sive geriatric assessment [15, 19] and staff education in
* Correspondence: email@example.com
University of the Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, Qld
Full list of author information is available at the end of the article
© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Craswell et al. Safety in Health (2016) 2:14
geriatric specific emergency medicine . Attention to
the design of a specific area in the ED to introduce nat-
ural lighting and noise reduction in an effort to be more
‘older people friendly’, similar to such areas for
pediatrics, is increasing in popularity . There is some
evidence that outreach interventions such as HiTH and
Hospital in the Nursing Home (HINH) as exemplars for
supported early discharge also result in decreased admis-
sion rates from RACFs to EDs and reduced length of
stay if admitted [13, 20, 21].
Changes in policy in Australia in 2010 to introduce a
four hour National Emergecy Access Target (NEAT) for
care of patients in the ED  in conjuunction with
increasing numbers of presentations to the ED from older
people from the community and RACFs has increased
pressure on EDs. Residents from RACFs are reported to
expereince extended ED stays and elevated levels of admis-
sion to hospital compared to other cohorts [23, 24]. Older
people who present to the ED are triaged at a higher rate
Scale [23, 25], compared to their younger counterparts.
Staff in EDs are generally not highly skilled in the care
of older people who generally suffer exacerbations of
chronic illness with multiple comorbidities. This is
reported to result in misdiagnosis of older people by ED
staff . These factors and a need to reduce length of
stay in the ED and inappropriate admissions of older
people have led to the development of an initiative to
provide specialist care for older people presenting to the
ED in a regional Hospital and Health Service in Queens-
land, Australia. The aim of this commentary is to define
this innnovation, the Geriatric Emergency Department
Intervention (GEDI), present evidence underpinning the
assessment methods used by GEDI and outline the simi-
larities and differences between GEDI and other ED
models of care for the frail older person.
The GEDI intervention is delivered in the ED by a multi-
disciplinary team consisting of a dedicated ED physician
and advanced practice nurses who have additional experi-
ence and education in gerontology and care of frail, older
people. The GEDI nurses work with the primary care ED
nurses and ED physicians providing targeted geriatric as-
sessment, multi-disciplinary decision-making and coordin-
ation of care for these more complex patients. Critical to
the integration of GEDI into the ED is the role the phys-
ician plays in driving acceptance, policy change, and clinical
support to overcome barriers to implementation. Advance
practice nurses, including a Clinical Nurse Consultant,
utilise community services to best meet the needs of pre-
senting older people from either the community or RACFs,
who can benefit from transition back to place of residence
week in ED and act in a consultant capacity providing a
brief review of all people over 70 years of age presenting to
the department. Based on this brief review, targeted geriat-
ric assessment helps determine those who will benefit from
rapid assessment and management of their concern in ED
with the intent of returning them home either to the com-
munity or RACF as soon as practical. The aim of the rapid
turnaround is to prevent the potential for complications
that often result from presentation to the ED occurring in
frail older people [4, 10, 27].
The GEDI team gather assessment information related
not only to the presenting condition, but also to the
extent of functional decline, cognitive deterioration and
overall frailty of older persons presenting to the ED. This
in turn informs clinical decision making and allows for
the assessment of the level of service required to support
safe discharge. An outline showing how the GEDI
service interacts with other health professionals and
services for liaison and referral can be seen in Fig. 1.
The GEDI team representxs a dedicated single point
of contact for RACF staff and PHPs referring older
people to the ED. They liaise with the older person, their
family and/or carer, ED physicians and Gerontologists
and specialist medical consultants along with the PHP
and other relevant primary care professionals. Discharge
summaries to the RACF and PHP provide communica-
tion of the care episode and details of all referrals.
Improved communication between healthcare services,
PHP and community services aims to build on Safety-II
principals , concentrating on what succeeds in the
ongoing care of the older person. The GEDI team also
facilitates direct admission pathways to orthopaedic sur-
gery and other specialties where appropriate. Finally,
education and upskilling of ED staff is provided to assist
in increasing the expertise of all ED staff to provide ap-
propriate care for this cohort. Research evaluation of the
GEDI model is currently in progress.
Evidence for GEDI intervention
The GEDI intervention was built on evidence from suc-
cessful aspects of existing models of care in hospitals and
EDs in the care of older adults suffering acute episodes of
decline in their health. Comprehensive Geriatric Assess-
ment (CGA) of older adults has been shown to result in
longevity and independence, less likelihood of requiring
admission to a RACF, reduced deterioration and improve-
ment in cognition . However, it is not clearly defined
how much comprehensive geriatric assessment should be
carried out in the ED. Completing a CGA in the ED has
limitations due to the length of time required to accom-
plish the assessment and the skills required of the health
practitioner to adequately complete the assessment .
GEDI nurses screen older people presenting to the ED to
identify those who can benefit from a targeted geriatric
Craswell et al. Safety in Health (2016) 2:14 Page 2 of 6
assessment. A targeted assessment reduces the length of
time required while still identifying deficits and the avail-
able resources needed to fulfil the requisites found. The
GEDI assessment of the older person involves utilising a
variety of tools to assess for recent changes in cognition,
function and risk of injury. The GEDI nurse will where
possible, assess for changes over time and will refer to in-
formation from a range of sources including, but not lim-
ited to, the patient, the medical records, the PCP, the
patient’s family members and other health and social care
professionals. Communication with the ED Physician and
Geriatrician when necessary, assists in building on the
findings of the assessment.
The Confusion Assessment Method (CAM) is utilised
by GEDI nurses to determine the presence of cognitive
impairment, particularly delirium in older adults. Delirium
is a common symptom in older adults presenting to the
ED and diagnosis is reported to be missed by Emergency
Physicians in between 56 and 76 % of cases [31, 32]. The
CAM is validated for use in ward areas, post-operative
recovery , intensive care  and is one of the few
geriatric tools validated for use in the ED . A limita-
tion of the CAM is that it is for use throughout the whole
hospital rather than being a tool specifically for use in the
ED and the particular circumstances of acutely unwell
older adults at first presentation to the ED. One other tool
the GEDI team use is the interRAI ED screener (Health
Etraining International Ltd.) for all non-RACF elderly pre-
sentations to the ED, a new risk assessment tool currently
Data from assessments performed by the primary nurse
in ED are also used by the GEDI team in determining
health status, functional decline and frailty in older people.
The Adult Deterioration Detection System (ADDS) score
 is calculated using the ADDS charting tool and used
as an early warning of deterioration. Health professionals
are reported to agree strongly on the ease of use of the
ADDS chart and subsequent risk scoring system .
Additional data collected by the primary nurse in the ED
such as falls risk and pain assessment are also considered.
The GEDI team focus on adding value to the information
that is already available for each elderly person in the ED,
leaving any other non-urgent activity to be done in appro-
priate areas of the hospital, the ward or via community
Similarities and Differences to other interventions in the
ED for acutely unwell older adults
Systematic reviews of interventions in EDs for older
people report the most successful interventions are de-
livered by multidisciplinary teams and use comprehen-
sive geriatric assessment (CGA) [15, 16]. In some areas
of Australia, specialist nurses operate as part of an Aged
Care Services Emergency Team (ASET), a State Govern-
ment initiative providing CGA in the ED, community
referral, fast-track assessment, education to ED staff, and
initiation of programs to improve ED outcomes .
The GEDI team utilises these interventions as part of
their care of the older person focusing on targeted
assessments as outlined earlier. However, differences lie
Fig. 1 GEDI model of assessment and interaction with support services
Craswell et al. Safety in Health (2016) 2:14 Page 3 of 6
in health professional collaboration, with assessments
completed by the allied health team and the ED primary
nurse, such as falls risk and pain assessment, being
included in the GEDI assessment. This improves the
efficiency of the collation of information and assists the
medical team in decision making about the care and
supported discharge of the older person. Some areas in
South Eastern Australia have included a “third door”
access to the ED for older people to provide sub-acute
services for older people bypassing the ED . These
"Healthcare for Older Persons Earlier" (HOPE) wards do
not have the same 4 h targets as ED, similar to short stay
units, often in or next to the ED, utilised in many hospi-
tals for ED presentations needing longer than 4 h but
not a full admission to hospital . Concerns have been
expressed that patients presenting to EDs are being ad-
mitted to these types of wards to bypass NEAT, but
without the necessary addition of service delivery. An in-
crease in admissions to these areas from ED has been
seen post 2010 .
Further to these models, the Aged Care Emergency
(ACE) service provides evidence based resources, tele-
phone support by an ED advanced practice nurse,
education and proactive case management aligned
with pre-established goals of care . Similarly, GEDI
have a dedicated telephone line that staff from RACFs,
or primary care areas such as PHPs, can use to contact
the GEDI team. However, the focus of the telephone
support is communication and provision of supporting
information about the older person should they be in
the process of transfer to the ED. This ensures that
the PHP remains central to the care of the older
person and any changes in care, to enhance recovery
from an acute illness, are directly discussed. Another
service providing outreach telephone support is
CARE-PACT which provides hospital-based telephone
referral by a clinical nurse, to any of four services: 1.
Hospital ED based treatment (for acute conditions
that cannot be treated within the RACF), 2. Referral to
existing primary care resources 3. Consultation with
the PHP and 4. Mobile assessment and treatment
resources . However, this model only caters for
older people from RACFs and research evaluation of
CAREPACT is not published in the literature at the
time of writing. HINH provides an outreach service
delivering acute care nursing support services, medi-
cation and equipment to the RACF nurse  to pre-
vent admission to hospital and fast-track discharge
back to the RACF for appropriate elderly people
thereby avoiding admission. GEDI does not provide
mobile assessment and treatment resources as the
current focus is on admission avoidance. Interestingly,
in the review of the ACE model, only hospital admis-
sion avoidance could be demonstrated .
GEDI is unique in its design relating to the key
personnel who operate as part of the GEDI team. A
passionate ED physician saw the need for improving the
care for older people presenting to ED and streamlining
their care to avoid the complications of long wait times.
This role has remained central and integral to the GEDI
model in creating acceptance and driving change in the
ED to embed this model of care as part of business as
usual. Finding the right mix of advanced practice nurses
with education, skills and experience in care of geriatric
populations to ensure the recognition of symptoms
particular to older persons and coordination with
appropriate services for discharge support is critical.
Together, these professionals target the frail older
persons presenting to the ED to assist in navigating
their journey through the health system safely and in a
This commentary has presented the GEDI model for
care for older people presenting to ED. Research
underpinning the interventions and assessments used
by the GEDI team demonstrates the evidence-based
foundation of this innovation. GEDI aims to improve
the care of older people while facilitating admission
avoidance where appropriate via referral to existing
community services. This enables care for older
people to be provided at a primary care level in the
persons’place of residence, be that the community or
RACF and therefore avoid complications of hospital
transfer and admission when other pathways are
ACD: Advance Care Plan—legal document outlining the health care to be
undertaken should the owner not be able to communicate that care to health
professionals; ACE: Aged Care Emergency—a model of care for older people
used in some hospitals in Australia; ADDS: Adult Deterioration Detection
System—a scoring system based on observations taken in emergency such as
pulse rates, respiratory rate, temperature, blood pressure to determine risk of
deterioration; ASET: Aged Care Services Emergency Team—a model of care for
older people in some hospitals across New South Wales, Australia;
CAM: Confusion Assessment method—a tool for measuring cognitive
impairment in adults; CGA: Comprehensive Geriatric Assessment—adetailed
assessment for older people to determine functional capacity; ED: Emergency
department—area in a hospital for emergency healthcare; GEDI: Geriatric
Emergency Department Intervention—the model of care described in this
report; HINH: Hospital in the Nursing Home—discharged from hospital to the
residential aged care facility or nursing home under the care of health
professionals who visit the facility to provide care; HITH: Hospital in The
Home—discharged from hospital to place of residence other than a residential
aged care facility or nursing home, under the care of health professionals who
visit to provide care; HOPE: Healthcare Older People Earlier—a model of care
for older people used in some hospitals in Australia; NEAT: National Emergency
Access Target—a targeted time frame to assess and care for people in the
Emergency Departments; PHP: Primary Healthcare Physician—the health
professional responsible for primary care of a person, in Australia this role is
generally carried out by a General Practitioner; RACF: Residential Aged Care
facilities—facility for providing long-term care for older adults, a nursing home
Craswell et al. Safety in Health (2016) 2:14 Page 4 of 6
The authors would like to acknowledge the contribution of Ms Colleen
Johnston to final proofing of this article.
The evaluation of this model of care is part of larger project funded by the
Department of Social Services, Australian Government: Aged Care Service
Improvement and Healthy Ageing Grants.
Availability of data and materials
AC, EM, AT, MW have made substantial contributions to conception and
design, or acquisition of data; AC drafted the manuscript; AC, EM, AT, MW
revised manuscript critically for important intellectual content; AC, EM, AT,
MW have given final approval of the version to be published and agree to
be accountable for all aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work are appropriately
investigated and resolved. All authors read and approved the final
The authors declare that they have no competing interests.
Consent for publication
All authors have consented to this publication.
Ethics approval and consent to participate
University of the Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, Qld
Sunshine Coast Hospital and Health Service, Nambour
General Hospital, Hospital Road, Nambour, Qld 4560, Australia.
Received: 24 September 2016 Accepted: 26 October 2016
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