A defining component of primary care,⁴ continuity of care decreased markedly from 1996–2006 in the United States. This decrease was associated with a drop in patient satisfaction, an increase in medical errors, duplication of services, unwanted treatments, polypharmacy, and decreased autonomy, and undermined quality and outcomes.⁵ The Institute of Medicine recommends that all participants in health care, including nursing and rehabilitation facilities, fully coordinate their activities and integrate communications; this would clearly improve elderly care.⁶

The PCP must ask before transfer: could the same care be provided in a non-ED setting? Sending a patient to the ED should not be a matter of convenience. The ED should not be used as the middle man: for example, a patient with a malfunctioning percutaneous endoscopic gastrostomy (PEG) tube could be sent directly to the gastrointestinal (GI) department or radiology (the same step the ED would have to take).

If you can refer directly to definitive care and avoid the ED you should.

A study of PCPs’ and emergency physicians’ (EPs’) ability to communicate and coordinate health care discovered haphazard communication and poor coordination, and that this situation undermines effective care and results in poor patient satisfaction and duplication of testing and treatment.⁷ The use of hospitalists to care for admitted patients results in more direct and immediate communication at the start of the hospitalization. Efforts at coordination generally fall to the diligence and training of the professionals themselves. Such direct contact can make a life and death difference.

As PCP, your report to the EP provides critical information, often accumulated over time, which would otherwise take time and effort to discover. Your direct report is the only guarantee this information will be known to the EP. Your report helps counter the difficulties inherent in the hectic ED environment and the complexities presented by the old. When transferring a patient to the ED, convey your detailed knowledge of the patient including the baseline level of function, your evaluation and impression of the acute event, your specific goals of care for the ED, and the patient’s overall goals of care as well.

Epidemiology

The aging of the United States population influences all segments of health care but especially the use of the ED.⁸ Elders do have greater needs for emergency care than other age groups.⁹ Currently, 20 million older Americans utilize EDs annually.¹⁰ Studies overwhelmingly agree this high level of use by older adults is appropriate.¹¹^,¹²^,¹³ The proportion of Emergency Medical Services (EMS) use in elders increases from 27% for age 65 to 84 to 48% among those 85 and older.¹⁴^,¹⁵^,¹⁶ Elders require more ED staff time and resources, receive more medications, and have higher rates of admission to both the hospital and critical care units.¹⁷^,¹⁸ From 33% to 50% of elder ED visits result in hospitalization, which is up to 4.6 times higher than rates seen in younger adults.¹⁹^,²⁰

Older adults are likely to have a PCP. Most do consult their PCP prior to ED use and are referred to the ED by their PCP. The one exception to high ED use by older adults may be the rural setting, where there is a disproportionately lower rate of ED use by older adults.¹⁹

The strain placed by older adult utilization of already overcrowded EDs calls for a review of both the appropriateness and patterns of PCP ED referral as well as the model of ED systems of care.²⁰^,²¹^,²²

Comorbidities, polypharmacy, lack of access to care, lack of mobility, poor social support, and frailty all contribute to the vulnerability, with increased morbidity and mortality of our older patients. Fifty-one percent of “social admit” elderly patients were found to have an acute medical problem: infections in 24%; cardiovascular issues in 14%; a neurologic event in 9%; gastrointestinal problems in 7%; pulmonary problems were noted in 5%; and another 5% with fracture, anemia, acute renal failure, or uncontrolled pain.²²^,²³ Patients sent to the ED for lack of social support suffered a 1-year mortality of up to 34%.²⁴

In the first 3 months after an index ED visit, 5% of discharged elder ED patients will die, 20% will require hospital admission, 20% require another ED evaluation, and from 10% to 48% suffer decline in functional abilities.²⁵^,²³^,²⁶ This high incidence of poor outcomes despite PCP follow-up suggests a complexity of need that far out spans the episodic ED visit.²⁷^,²⁸ These outcomes suggest the underlying issue is not the acute event for which the ED was designed, but a quietly ongoing process. Thus a substantial proportion of elders would likely be better served in non-ED settings and with active follow up, coordinated by their PCP,²⁹^,³⁰ who ideally should be vigilant for continued deterioration of older patients who attended the ED.

Systems-based practice (sbp)

This is one of six core competencies required in all physicians before they are certified to graduate by any residency program. SBP is defined by the Accreditation Council of Graduate Medical Education (ACGME) as: an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.³¹^,³²

As a PCP, your distance from an ED, the specific services it provides, and the ease of transportation to and access of those services are critical components of SBP in your practice setting.

Access to the ED

Seventy-one percent of the U.S. population can access a general comprehensive ED within 30 minutes, and 98% has access within 60 minutes. Access to a teaching hospital ED is more difficult, with 16% access in 30 minutes and 44% within 60 minutes.³³ Such aspects can compromise the success of therapies for acute myocardial infarction, stroke, and sepsis. At least one rural study of three communities confirms that the more limited access of rural elders can be addressed using preplanned transport methods for acute emergencies, and by being well prepared to provide emergency care on site. In fact, there were probable advantages for these communities relative to nonrural settings.³⁴

The “geriatric emergency department” (GED)

Many attempts to optimize ED care for the old have been made; chief among these are geriatric service lines and development of a geriatric ED (GED). In addition to incorporating the Affordable Care Act’s (ACA) focus on maximizing resources in the Medicare population, a further goal is to appropriately triage those requiring inpatient care, and to identify—and effectively implement—services for those who can be discharged. ³⁵^,³⁶^,³⁷

GEDs have the following characteristics:

1. Enhanced ED staffing and administration: geriatrically trained registered nurses (RNs), pharmacists, social workers, specialist geriatricians, and care coordinators. Geriatrician ED consults have resulted in avoidance of admission for 85% of the older patients evaluated.⁸ Moderate improvements in the provision of physical and occupational therapy are also noted.

2. Screening: GEDs utilize screening to shift to being proactive rather than reactive. Screenings identify high risk individuals, decrease never-events, and identify need for specific services. Linkages to care for the problems identified are crucial; these generally involve primary care and community services.³⁶

3. Case management: This is reported to improve the health, social, and service utilization outcomes arising from ED visits. Core components were reviewed as to their influence on effectiveness of interventions.³⁷ More than eight of these key components produced a trend toward better outcomes: a validated risk stratification tool in a full geriatric assessment, significant nursing involvement in clinical evaluation, leadership roles, initiation of care and disposition planning from the ED, and having post-discharge follow-up mechanisms in place.

4. Staff education: In view of their recognized lack of geriatric-specific training,³⁸ many training programs and curricula have been developed for EMS providers, ED nurses, and EPs.^39–43

The eight core competencies of emergency medicine care for the elderly are atypical presentations, medication management, trauma (including falls), emergency intervention modifications, effect of comorbidity, cognitive and behavioral disorders, and transitions of care.

Common emergencies in geriatrics

The three most common complaints in elder ED patients are: chest pain, shortness of breath, and abdominal pain.⁴⁴^,⁴⁵ The differential of each of these obviously includes life-threatening emergencies.

The most frequent medical diagnoses made in older ED patients are: ischemic heart disease, congestive heart failure, cardiac dysrhythmias, syncope, acute cerebrovascular accidents, pneumonia, abdominal disorders, dehydration, and urinary tract infections.⁴⁶ Surgical emergencies in ED elders are primarily due to injuries sustained in a fall. Injuries are the seventh leading cause of death in the elder population.⁸ Falls are a critical event in this population (see separate chapter) with the cause being as significant as the damage, due to high recurrence rates.

CASE 1 Shortness of Breath

Mr. Edward Harris is a 69-year-old male with COPD, who presents to your office with a complaint of shortness of breath. He states his family members have been sick with a cold, and he is concerned he may be catching it as well. He has been coughing up green mucus for the past 4 days, and he has been wheezing more and more each day. He has an albuterol inhaler at home, and he has had to use it every hour throughout the day. He has been having “low-grade fevers” but denies chills, vomiting, chest pain, or leg swelling.

He has a past medical history of hypertension, diabetes, and coronary artery disease (CAD). He admits to smoking 1–2 packs per day for the last 25 years. He denies illicit drug or alcohol use. He does require oxygen at home and uses 2L of O₂ by nasal cannula.

His vital signs are HR 105, BP 158/95, RR 26, Sat 85% on room air, which corrects to 90% on 2L and up to 92% on 6L. On exam, he is obese, looks uncomfortable, is able to speak only in 3–4 word sentences due to SOB, has moderate subcostal retractions, and has diffuse wheezing throughout. His peak expiratory flow rate (PEFR) upon arrival is measured at 160 L/min. He states his normal is around 400 L/min.

1. What could have triggered this?

2. What specific dangers do you anticipate in this case?

COPD exacerbations

Exacerbations are most often triggered by a viral or bacterial infection ⁴⁸ but can also be triggered by cold weather, narcotic use, CHF, or anemia, among other triggers. It is essential to be able to differentiate between a mild exacerbation, which could be treated in the office, and a more severe one that requires transfer to the closest ED. The most life-threatening components of an exacerbation are hypoxemia and hypercarbia.⁴⁹

Hypoxia and hypercarbia can present similarly with symptoms such as headaches, agitation, confusion, lethargy, and in severe cases, can lead to seizures or coma. Impending respiratory collapse will be manifested by the signs above plus tachypnea, tachycardia, hypertension, accessory muscle use, pursed lips, and altered mental status. The retention of CO₂ heralds acute respiratory failure. The idea that oxygen can induce hypercarbia is largely a myth.⁵⁰ Oxygen should not be withheld from patients with hypoxemia. However, do not apply high flow oxygen (defined as 8–10 L/min); rather titrate oxygen treatments, which reduces mortality, hypercapnia, and acidosis in acute exacerbations of COPD.⁵¹^,⁵² Unless you can apply positive pressure or intubate the patient, maintain SpO₂ between 88% and 92% as this was found to reduce mortality by 58%.⁵³ Spirometry—to identify airflow obstruction—should be obtained in COPD patients with altered respiratory symptoms.⁵⁴

Investigation

• Oxygenation: Initial measurement of oxygen saturation and, if available, arterial blood gas can serve to give a quick assessment of severity of the exacerbation.

• Pulmonary function tests: If patient is able to comply, obtaining a FEV1 or PEFR can help determine severity of the exacerbation. FEV1 is preferred but is rarely readily available in an acute setting. PEFR of <100 L/min, FEV1 <1 L, along with worsening function on sequential testing despite treatment, are all indicative of a severe exacerbation.⁴⁹^,⁵³

• Ancillary testing: A chest x-ray can help identify underlying triggers of the exacerbation such as pneumonia or CHF. An ECG can help rule out ischemia or arrhythmias, such as multiple atrial tachycardia (MAT). Complete blood counts, electrolyte panel, and D-dimer should be performed when clinically indicated but should not be used to assess severity of a particular exacerbation.

Treatment: Interventions that can be performed in an outpatient setting

• Oxygenation: Administer O₂ by nasal cannula, face mask, or by the most appropriate method.

• Bronchodilators: Short-acting beta 2 agonists such as albuterol ⁵⁵ and anticholinergic agents such as ipratropium are both equally effective in acute COPD exacerbations and have been shown to lead to shorter stays in the ED and improved outcomes when used concomitantly.⁵⁶ Long-acting beta 2 agonist or long-acting anticholinergic agents have no role in acute COPD exacerbations.

• Corticosteroids: Administration of either IV or PO steroids during an exacerbation can help prevent return of symptoms after an exacerbation but do not prevent hospitalization in an acute setting. This is likely due to the onset of action of up to 6 hours from administration.⁵⁷ It is prudent to give steroids to a patient who is going to be discharged from the office. There is no difference in outcome or onset of action in using IV versus PO steroids.

• Antibiotics: Most common pathogens are streptococcus pneumonia, hemophilus influenza, and moraxella catarrhalis. Antibiotics should be given if concomitant infection is suspected from symptoms such as increased sputum or fever.⁴⁸

Treatment: Interventions that require transfer to the closest ED

• Noninvasive positive pressure ventilation (NPPV): Indicated for moderate to severe exacerbations as determined by worsening tachypnea >25 breaths/min, dyspnea with accessory muscle use, moderate to severe acidosis (pH<7.35), or hypercapnia (PaCO2 > 45mm Hg).⁵⁷ If a patient is deemed to require NPPV, he/she should be transferred to the nearest ED as soon as possible. Patients in respiratory distress that undergo NPPV have better short-term mortality, decreased intubation rates, and decreased length of hospital stay.⁵⁸

• Mechanical ventilation: if a patient continues to deteriorate despite all the above interventions, endotracheal intubation is the next required therapy. This should always be determined by and performed in an ED or ICU setting.

If there is no improvement in clinical status after treatment with oxygen and bronchodilators, transfer to the nearest hospital is warranted for further treatment. In a patient who is stable without severe respiratory distress, stable oxygenation, and no requirement of continuous nebulizations, yet has persistent wheezing or lack of improvement, direct admission to an inpatient setting may be appropriate. For a patient who is continuing to deteriorate or a patient who shows signs of impending respiratory collapse as outlined above, immediate transfer to the nearest ED should be arranged.

CASE 1 Shortness of Breath (continued)

You start Mr. Harris on a combination albuterol/ipratropium nebulization, and your plan is to give him prednisone and an antibiotic before going home. However, after three intermittent 15-minute nebulizer treatments, he fails to improve. He is now experiencing worse SOB, and on exam, he is breathing around 30 breaths per minute, he is pursing his lips with each breath, can only say 1–2 words at a time and has more visible retractions despite the nebulized treatment. He starts to appear more confused, requiring repeated questions for him to comprehend what you are asking. He is unable to perform the PEFR measurement.

What could be the cause(s) of this decline? What is your next step?

You determine he would benefit from NPPV and further treatment, so you expedite a transfer to the closest ED. You call EMS who arrive within 7 minutes. They give him an albuterol nebulization and place him on a portable continuous positive airway pressure (CPAP) machine and take him to the closest hospital.

You follow up and find out he required admission to the ICU for continuous NPPV and nebulizations. He was able to avoid intubation but was subsequently treated for pneumonia. He stayed in the ICU for 2 days, after which he was transferred to the floor to continue treatment and was discharged home in a few days with PO steroids and antibiotics.

What precisely indicated that he should be transferred to the ED from the office?

Syncope

CASE 2 Syncope

Mrs. Vera Smith is a 72-year-old female who is brought to your office by her husband hours after experiencing syncope. The patient states she was napping on the couch, then awoke and walked to the kitchen. While walking, she became very dizzy and felt like her vision was closing in on her. Her husband noted she turned pale very quickly and then passed out. He was able to hold her so she did not fall. He laid her down gently and within a few seconds she was awake. Currently, she denies any discomfort. None of these symptoms has recurred since the event. She states there has been a “stomach bug” going around in her family, and she has had five episodes of vomiting and diarrhea during the last 2 days along with poor appetite. She has otherwise been well and denies any recent fevers, chills, chest pain, trouble breathing, and does not recall any other similar episodes of fainting. She has a history of GERD and asthma but is otherwise healthy. She does not smoke, denies illicit drug use, and only uses alcohol with family during holidays. Her vital signs are HR 105, BP 132/88, RR 18, O₂ Sat 99% on room air. On physical exam, you note the patient does have moderately dry mucous membranes but otherwise appears comfortable. Your examination of her heart, lungs, and abdomen is normal.

Her urine specific gravity is >1.02, with positive ketones and without glucose or leukocytes; an ECG shows sinus tachycardia without any other abnormalities. Upon standing, her BP drops to 105/70 and her HR increases to 120 and she reports feeling dizzy.

1. Under what conditions is it reasonable to treat an elder with syncope in the office and discharge home?

2. What features of the patient’s PMH define a high risk patient who warrants hospitalization for syncope evaluation?

3. In what circumstances is it safe to bypass the ED and directly admit an elder with syncope?

CASE 2 Syncope (continued)

You assess her as having probable simple dehydration, take blood for a BMP and Hgb, and advise her to return home, to not be alone in the house for a day or two (her husband is “always” there), to drink a lot of extra fluids (excluding her favorite fluids of tea and coffee), to stand up slowly after being recumbent in bed or in a chair, and to return for orthostatics by your nurse in 2 days.

Management of syncope

The 2008 American College of Emergency Physicians Clinical Policy: Critical Issues in the Evaluation and Management of Patients Presenting With Syncope,⁵⁹ recognizes the extremely low yield of non-directed testing in syncope evaluation.⁵⁹ On admitted syncope patients, the most commonly performed ED studies are ECG (99%), cardiac markers (95%), and CT head (63%). Markers and CT head affected diagnosis or management in less than 5% of cases and were diagnostic in <2%.⁶⁰ Although orthostatic blood pressure readings are obtained in about a third of patients, these evaluations affected diagnosis in up to 26%, management in up to 30%, and determined etiology in from 15% to 21% of patients. Obtaining an ECG and a hematocrit is warranted for most cases of syncope, with further testing normally being low yield. For suspected cardiogenic syncope, a chest x-ray and cardiac enzyme panel may be warranted. However, unless there exists a strong suspicion of neurologic cause or if head trauma is involved, a head CT is rarely warranted.

Generally, purely vasovagal or orthostatic hypotension syncope (or drug induced orthostasis) with a correctable cause has no increased risk for future adverse events.⁴⁹^,⁶¹

Symptomatic treatment and adequate follow-up is therefore appropriate. For orthostatic hypotension, hydration and re-evaluation is prudent. If symptoms improve with therapy, discharge home is appropriate.

On the other hand, cardiogenic or neurologic syncope requires immediate hospitalization for further evaluation. Ideally, if direct inpatient hospitalization can be arranged from the clinic or office, the patient can be sent straight for admission. Otherwise, sending the patient to the ED should be the next step.

If a clear etiology of the syncope cannot be determined, the patient should be risk stratified as low risk for adverse events. You should determine who can be discharged home with follow-up, who will need admission to an inpatient setting for further workup, and who requires ED intervention. Several clinical criteria and clinical decision rules (CDRs) exist to aid with risk stratification; unfortunately, there is no particular set of criteria that has been shown to be superior, and most have been proven to be inadequate to estimate risk in certain clinical settings.⁴⁹^,⁶¹

The San Francisco Syncope Rule ⁶² has five predictors of adverse events: (1) history of CHF; (2) hematocrit <30; (3) ECG changes consisting of any morphologic changes not seen on prior ECG, any dysrhythmias, or nonsinus rhythm either on strip or on monitor; (4) shortness of breath by history; and (5) systolic BP < 90 mmHg. If ANY of these criteria is met, the patient is considered high risk and warrants further evaluation. These rules have shown a 96% sensitivity and 68% specificity for serious outcomes defined as death, MI, arrhythmia, PE, stroke, SAH, hemorrhage, or any condition requiring return to the ED at 7 and 30 days.³ However, the sensitivity and specificity of these rules have been shown to decrease significantly in the elder population.⁶³

A different CDR, the OESIL score (Osservatorio Epidemiologico sulla Sincope nel Lazio), takes into account age >65, known CV disease, abnormal ECG, and lack of a presyncopal prodrome as high risk predictors—the higher the score, the higher the predicted mortality at one year. This tool had a sensitivity of 95% and specificity of 31%.⁶⁴

CASE 3 Syncope with Risk Factors

Mr. Arthur Jones is an 81-year-old male with known congestive heart failure who presents after passing out earlier this morning. The patient was sitting on a park bench resting midway through his morning walk because he developed shortness of breath and chest pain. He suddenly became unresponsive. A neighbor who witnessed the episode reports that he was unconscious for about a minute. Since then, he has remained asymptomatic other than feeling weak and having some shortness of breath.

In addition to CHF, Mr. Jones also has hypertension, diabetes, is a smoker, and has been told he may need surgery for one of his heart valves that is “not working properly.” His vital signs in your office are HR 87, BP 88/65, RR 22, SO₂

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