From MD Consult, March 16, 2005 by Doug Kaufman

ST. LOUIS (MD Consult) - With an aging population, including many baby boomers entering or approaching senior citizen status, emergency rooms are faced with overcrowding and staff shortages, a problem that needs to be addressed.

"Most specialties are recognizing that there is an impending demographic tsunami," said Dr. Christopher Carpenter, former geriatric emergency room specialist at Barnes-Jewish Hospital in St. Louis. "It''s coming our way, and we need to get prepared for it. It''s a demographic surge we''ve never seen before. The 85-and-up age group, all-comers, is growing four times faster than any other age group. With our already overcrowded EDs, this is going to be a real problem."

"It''s already an issue," said Dr. David Carr, a Barnes-Jewish geriatrician and clinical director of the Division of Geriatrics and Nutritional Science at Washington University School of Medicine in St. Louis. "There are a lot of issues I see that are already clinical care problems. I''m sure with the volume of what we''re going to see here for older adults and their medical problems, we''re training another generation to be very doctor- and hospital-dependent. I think you''re going to see people who, when they get symptoms and they worry about them, they want some immediate reassurance. I just think the volume is going to continue to go up for ER visits in older adults."

The problems need to be identified before a treatment plan can be organized, Dr. Carr said.

"One of the barriers is simply a lack of appropriate diagnosis," he said. "You take an older adult who comes in to an emergency room, and they may have some cognitive impairments, some forgetfulness. We know that they don''t always present with classic symptoms of elevated fever and white count. It''s often hard to get a diagnosis. You have to be savvy to the presence of geriatric syndromes and how they may affect your patient. It might be easy for me to do since I know my patients and I know how they present. But you go into an ER at two in the morning with a different doc - that''s a huge barrier."

Some ERs have developed clinical decision rules for deciding how to treat patients.

"So far we''ve developed very simple ones for things like ankle sprains and blunt trauma neck injuries," Dr. Carpenter said. "What they do is tell us which patients, on a clinical basis alone, we can exclude without doing imaging of the ankle or the blunt trauma. It''s kind of like a triage tool, but it''s more for physicians, although they have been applied to nursing and triage nurses as well. But on a more complicated basis, we''re now trying to develop clinical decision rules for medical conditions like syncope, or fainting. And figure out which patients ... require an inpatient evaluation, monitoring echocardiography, and so forth, and which patients we can safely disposition home, without an in-patient work-up, for subsequent out-patient follow-up."

Falls, for instance, are a frequent problem in the elderly population, Dr. Carpenter said.

"We need to figure out which patients who come in to the ED with a fall need to be evaluated further, either as an in-patient or in a structured outpatient environment, for subsequent fall risk," he said. "Because eventually these falls do result in injuries. Statistically, it''s the leading cause of traumatic death among the elderly - a simple fall from standing (position)."

Research is needed to develop more detailed clinical decision rules. Some ED doctors, Dr. Carpenter said, believe all patients who have fallen should be admitted. But he favors a careful case-by-case consideration.

"If we can even take 20 percent away and say, ''Twenty percent can go home safely and have out-patient follow-up or no further follow-up,'' that will take some of the burden off the in-patient bed crunch and the ED overcrowding that''s occurring," he said. "So what we''re trying to develop at a national level is researchers who can answer questions to decrease the current burden in the emergency department. But that takes years to develop."

Senior citizens represent 13 percent of the population but account for 15 percent of ED visits, Dr. Carpenter said.

"So they''re already a disproportionate amount of the ED visits we see," he said. "They take up about one-third of healthcare spending nationally and occupy about 50 percent of physician time, based on a 2004 survey. Generally, emergency physicians feel they are the most difficult, most time-consuming patients to deal with. And ultimately the most frustrating as well, for those reasons. So right now they''re taking up a disproportionate amount of ER beds, a disproportionate amount of ED, regular nursing beds, and a disproportionate amount of ICU beds. As well as causing a lot of physician angst and discomfort."

Some of the visits are unnecessary.

"My mother was a case in point," Dr. Carr said. "She got what looked to be a viral illness. She wasn''t feeling well. I tried to reassure her that I thought she could hold the course. She got worried, got nervous, and insisted on going to the emergency room. She was there for eight hours, and got a CT scan of her abdomen and pelvis. (It cost) probably several thousand dollars, and they concluded she had the stomach flu and sent her home, with, really, no prescription. Just an example of people wanting that immediate reassurance."

Part of keeping patients out of the ER involves paying attention to medical status changes before they get out of hand.

"Call early and call often. I tell that to patients and family members," Dr. Carr said. "... We need to be proactive and jump on things right away. Especially now during flu season. The margin of error for many of our frail older adults is very small. If they get to the point where they''re toxic and they end up in the emergency room, it''s very rare that it just came up. They''ve probably been battling it for a few days. ... If I don''t get called or my colleagues don''t get called, there''s not a whole lot we can do about it."

There isn''t a quick solution, Dr. Carpenter said, but the areas to improve are clear. For instance, nursing home patients often arrive in the ED with minimal medical background information.

"We don''t have records of when their last hospitalization was, where they were hospitalized, what their code status is, who their primary care physician is, who the family is - to contact for questions, drug allergies, recent drug changes," he said. "Many times they arrive with none of that information."

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