ABSTRACT
Study Objectives: In 2018, the US Department of Veterans Affairs (VA) Offices of Emergency Medicine and Geriatrics & Extended Care partnered to improve acute, unscheduled care for older Veterans. The goals of the partnership were to create a VA core team to promote best geriatric emergency care practices via standardization, education, and Geriatric Emergency Department (ED) Accreditation (GEDA) through the American College of Emergency Physicians. The objective of this will be to describe the current progress of GED implementation and dissemination at the VA. Study Design / Methods: This is a descriptive summary of Veterans seen in VA EDs from January 2018 - March 2022 with data from the VA Corporate Data Warehouse. We collected GED implementation data by extracting rates of screening for documented geriatric assessments, health care utilization patterns, and demographic data from ED visits. We compared EDs with and without GED implementation (non-GED versus Level 3 to 1 (L1 = highest GEDA implementation)) based on date of accreditation [RLCD1] application submission or approval. Standardized GED assessments in the electronic health record did not begin until 2019[RLCD2], although some sites collected local data on GED programming in 2018. Results / Findings: During this implementation phase, 1.07 million unique Veterans 65+ years in age made 4.08 million VA ED visits. Over 40% of these visits were made atoccurred in a VA ED seeking or receiving GEDA. Forty percent of VA EDs (44/111) began GED initiatives and applied for or received GED accreditation (4 as Level 1, 7 as Level 2, and 33 as Level 3);28 (25%[MCM((3] [RLCD4] ) of VA ED are now GED accredited. The nationally standardized GED assessments include the Identification of Seniors At Risk (ISAR), Delirium Triage Screen (DTS), Brief Confusion Assessment Method, Mini-Cognitive assessment, a falls risk screen, Activities of Daily Living, and Caregiver Burden screen. The most heavily adopted screens completed in GEDs were the ISAR and DTS. ISAR screening documentation continuously increased, especially at Level 1 GEDs, (from 0% in 2018 to 57.5% of Veterans screened in 2022). The DTS screening documentation also increased at Level 1 GEDs (from 0% in 2018 and 2019 to 23.7% in 2022). There were no differences by admission rates when comparing Level 1 GEDs versus non-GEDs (27.9% vs. 27.3%;p=0.18). GEDs, however, had lower ED revisit rates at 24 hours (1.5% vs. 2.1%), 72 hours (4.0% vs. 5.3%), 30 days (23.3% vs. 25.1%), and 90 days (33.8% vs. 36.3%) compared to non-GEDs (all p<0.01) [RLCD5]. Conclusion(s): The VA is the country's largest integrated health care system implementing and disseminating geriatric emergency care. Adoption of geriatric-focused screenings has steadily increased over time as more facilities pursue GEDA. With 40% of its EDs seeking GED accreditation, and 25% sites achieving this (during the COVID pandemic), the VA approach to implementation and spread of geriatric emergency care can be a model for other health care systems. No, authors do not have interests to disclose Copyright © 2022
ABSTRACT
Study Objectives: Geriatric emergency department (GED) accreditation (GEDA) through the American College of Emergency Physicians requires developing a strategic plan for education, equipment, policies, environment, staffing, and quality improvement. To support Veterans Affairs (VA) EDs in achieving accreditation, an interdisciplinary group of leaders in the VA National Offices of Emergency Medicine and Geriatrics and Extended Care and subject matter experts created a council that hosted a bootcamp, mentored support, created a Web site housing sample policies, staffing descriptions, workflows, and order sets. Additional individualized support was provided to assist with implementation of GED processes during the COVID-19 crisis. We sought to identify feedback on the accreditation process to inform onboarding of future cohorts. Methods: This was a dissemination plan for GED implementation at 20 VA EDs. VA medical centers were invited to submit an application for GEDA mentored support and fee waiver. An in-person kickoff bootcamp was held February 2020 for 10 VA EDs applying for Level 1 or Level 2 GEDA. As part of the planned quality review and to prepare for future VA GEDA, we performed follow-up surveys on the accreditation process, new interdisciplinary services relationships established, outcomes, and feedback on the process. Results: A total of 26/110 VA facilities with EDs applied for VA GEDA support;10 were accepted for the in person bootcamp and virtual support and 10 additional for virtual support only. Nineteen supported sites have applied for accreditation and 14 have received accreditation: one level 1, four level 2, and nine level 3. Mean ED visit volume in 2019 for accredited sites was 25, 475 (range 8, 212-42, 589 visits/year) with 47% of visits made by veterans 65 years or older (range 33-60%). Sixteen sites responded to the survey. Ninety-four percent (15/16) described new interdisciplinary services (figure 1). When asked what accomplishment associated with the accreditation process they were proud of, 6 reported ED outcome improvements, 12/16 reported connecting patients to VA services, and 13/16 reported improved patient care team engagement. Feedback on the process suggested the need for standardization of data collection, workflow, and documentation, which has led to the development of a central dashboard and patient care note with standardized geriatric screens and assessments. Conclusion: A central supported system allowed 14 VA EDs to achieve geriatric ED accreditation despite the COVID pandemic. Almost all facilities reported they formed new associations with interdisciplinary services as a result of the accreditation process. More than half reported improved patient care team engagement and connection to VA services as additional accomplishments. Feedback has led to increased standardization of geriatric emergency care assessments across the healthcare system. [Formula presented]