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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com




Saturday, July 18, 2015

Servicios de Emergencia Geriátricos

This document is the product of two years of consensus-based work that included representatives from the American College of Emergency Physicians, The American Geriatrics Society, Emergency Nurses Association, and the Society for Academic Emergency Medicine. 
APPROVED BY THE ACEP 2013; SAEM 2013; AGS 2013; ENA 2014
According to the 2010 Census, more than 40 million Americans were over the age of 65, which was “more people than in any previous census.” In addition, “between 2000 and 2010, the population 65 years and over increased at a faster rate than the total U.S. population.” The census data also demonstrated that the population 85 and older is growing at a rate almost three times the general population. The subsequent increased need for health care for this burgeoning geriatric population represents an unprecedented and overwhelming challenge to the American health care system as a whole and to emergency departments (EDs) specifically. Geriatric EDs began appearing in the United States in 2008 and have become increasingly common. The ED is uniquely positioned to play a role in improving care to the geriatric population. As an ever-increasing access point for medical care, the ED sits at a crossroads between inpatient and outpatient care (Figure 1). Specifically, the ED represents 57% of hospital admissions in the United States, of which almost 70% receive a non-surgical diagnosis. The expertise which an ED staff can bring to an encounter with a geriatric patient can meaningfully impact not only a patient’s condition, but can also impact the decision to utilize relatively expensive inpatient modalities, or less expensive outpatient treatments. Emergency medicine experts recognize similar challenges around the world. Geriatric ED core principles have been described in the United Kingdom.
Furthermore, as the initial site of care for both inpatient and outpatient events, the care provided in the ED has the opportunity to “set the stage” for subsequent care provided. More accurate diagnoses and improved therapeutic measures can not only expedite and improve inpatient care and outcomes, but can effectively guide the allocation of resources towards a patient population that, in general, utilizes significantly more resources per event than younger populations. Geriatric ED patients represent 43% of admissions, including 48% admitted to the intensive care unit (ICU). On average, the geriatric patient has an ED length of stay that is 20% longer and they use 50% more lab/imaging services than younger populations. In addition, Geriatric ED patients are 400% more likely to require social services. Despite the focus on geriatric acute care in the ED manifest by disproportionate use of resources, these patients frequently leave the ED dissatisfied and optimal outcomes are not consistently attained. Despite the fact that the geriatric patient population accounts for a large, and ever increasing, proportion of ED visits, the contemporary emergency medicine management model may not be adequate for geriatric adults. A number of challenges face emergency medicine to effectively and reliably improve post-ED geriatric adult outcomes. Multiple studies demonstrate ED physicians’ perceptions about inadequate geriatric emergency care model training. Many common geriatric ED problems remain under-researched leaving uncertainty in optimal management strategies. In addition, quality indicators for minimal standard geriatric ED care continue to evolve. Older adults with multiple medical co-morbidities, often multiple medications, and complex physiologic changes present even greater challenges. Programs specifically designed to address these concerns are a realistic opportunity to improve care. Similar programs designed for other age groups (pediatrics) or directed towards specific diseases (STEMI, stroke, and trauma) have improved care both in individual EDs and system-wide, resulting in better, more cost effective care and ultimately better patient outcomes."