Kevin Biese, MD & Megan Donovan, MBA - The Value of Geriatric Emergency Departments Pt. 1 Move to Value

Today we talk to Dr. Kevin Biese, from the UNC Chapel Hill School of Medicine and Megan Donovan, an Atlanta-based independent management consultant, about Geriatric Emergency Departments and the role they play in value-based care.
Transcript:
I’d like to start off by asking what is a Geriatric Emergency Department, also known as a GED, and how is it different from a standard ED?
Kevin: Thank you so much Thomas. And I'll go ahead and just give a little bit of background history on that. So, anything that I say that suggests about how emergency departments can do better comes from an understanding or perspective that there's a number of wonderful people that work in emergency departments, but that the system isn't really quite designed right for the needs of older adults. And when I say older adults, I really mean vulnerable older adults. Not 66-year-olds who sprain their ankles playing tennis. I mean it can always be better, but I'm really thinking about people with cognitive deficits, perhaps with needing caregiver assistance, with complicated medical history, with multisystem issues like you know like heart failure or lung disease. A lot of complicated issues. The system of emergency medicine isn't optimally designed for this specific, complex, multilayered needs of older adults by that definition.
And so, an geriatric ED, just a brief story if I can. I was a third-year resident on a four-year emergency medicine program at really good program in Boston. So, it doesn't matter, at Mass General. And it’s Mass General, they’re supposed to be really good. Like they're really, but we didn't learn anything about the care of older adults, specifically. Like when I was at residency, we knew that a 2-year-old wasn't a 40- year-old and we knew that 80-year-olds got sick more than 40-year-olds. I mean you could kind of tell by looking around. But there wasn't like a month of like, well what's different about older adults, or what is polypharmacy mean, or what about hyper, what is the difference between delirium, dementia, and depression, and why would that matter. That wasn't part of what we learned. So, one day I'm leaving the end of a 12-hour shift at Mass General in the trauma section, and there is this older woman on a cot in the corner. And I didn't think anything of it. We were really busy. We were full, heart attack, stroke, gunshot. There was always an older person like kind of waiting to go upstairs or something. And I just, I was tired, stinky, exhausted. Well, I came back 12 hours later, because we were you know in 12-hour shifts, same woman, same corner, same cot. And I got mad. I didn't know that she had hypoactive delirium. I couldn't even have told you exactly what that was. I didn't know that we'd probably given her a urinary tract infection through prolonged foley use. I did know that that cot looked really uncomfortable, and she probably needed something to eat. And I knew that like my grandma helped raised me and this didn't seem OK. You didn't have to go to geriatrics training for this to seem like, “wait a second. You were here 12 hours ago and here you are now, same place. This can't be good.”
And so, we started to do some stuff around emergency medicine in residency and then when I came here to the University of North Carolina, Jan Busby-Whitehead, who's the chief of geriatrics, sort of adopted me. And a lot of the work that we have done in the decades since come from that initial awareness of how can we do better for older adults in the emergency department. In about 2013, a group of us in emergency medicine, and my colleagues actually wrote some geriatric ED guidelines about how to do best practices in geriatric emergency medicine. That was really important. We were fortunate to get that like signed off by the big nursing and physician organizations in geriatrics and emergency medicine. And we established best practices. And then about three...