Enhancing Emergency Medical Care for Seniors Could Reduce Hospital Admissions
Applying palliative care principles to emergency departments may reduce the number of geriatric patients admitted to intensive care units, possibly extending lives and reducing Medicare costs.
Applying palliative care principles to emergency departments may reduce the number of geriatric patients admitted to intensive care units, possibly extending lives and reducing Medicare costs, according to a three-year analysis by Mount Sinai researchers set to be published in the May edition of Health Affairs, which can be found online.
“Data show that more than half of Americans ages 65 and older are seen in the emergency department in the last month of their lives, and that the number and rate of admissions to intensive care units among older adults who are seen in the ED have also increased,” said Corita Grudzen, MD, the lead author of the study and former Mount Sinai Health System physician. “Our findings suggest that early palliative care inpatient consultation can improve care for older patients, decrease hospital lengths-of-stay and costs, and even extend life. The potential for this approach to improve the quality and value of geriatric emergency care warrants continued study.”.”
The changes in emergency care examined in this preliminary analysis were developed through Mount Sinai’s Geriatric Emergency Department Innovations in Care Through Workforce, Informatics and Structural Enhancements program, also known as GEDI WISE.
Under the GEDI WISE model, which was developed by a multidisciplinary team led by Lynne D. Richardson, MD, Professor of Emergency Medicine and of Population Health Science and Policy at the Icahn School of Medicine at Mount Sinai, changes in ED staff training and practice (workforce enhancements) were introduced at The Mount Sinai Hospital, including role redefinition and education in palliative care principles. As part of the training:
• ED triage nurses learned to screen patients aged 65 and older to identify those at high risk of ED revisit and hospital readmission
• ED nurse practitioners learned to identify high-risk patients suitable for and desiring palliative and hospice care, and how to expedite referrals
Screening of ED patients with the Identification of Seniors at Risk tool was instituted in October 2012. Researchers found that 59 percent of the 8,519 visitors to Mount Sinai’s ED ages sixty-five and older who were screened with the tool had a score that indicated an increased risk for revisit and readmission. The five most common presenting diagnoses among this cohort were chest pain, shortness of breath, malaise and fatigue, abdominal pain, and dizziness.
Specifically, Dr. Grudzen’s analysis found that using the GEDI WISE model brought about a 1.4 percent—in the ICU admission rate for ED for patients ages 65 and older at the Mount Sinai Hospital. This decrease remained significant even after changes in comorbidity and other key characteristics of ED patients in this age group were accounted for.
The absolute reduction of 1.4 percent in ICU admissions from the ED during the study period, in which there were 38,240 unique ED encounters, corresponded to a decrease of 535 ICU admissions. Assuming that these patients were admitted to the hospital, this drop in admissions would produce an estimated savings of more than $3.14 million to Medicare.
“This study shows that identifying emergency patients who would benefit from palliative care interventions may both improve the quality of care and reduce costs,” said Dr. Richardson. “This could result in a better match of older adults’ goals of care with the environments to which they are discharged from the ED, including decreased admissions to the ICU, and increased referrals to hospice and palliative care provided at home.”
The project was supported by a grant from the Centers for Medicare and Medicaid Services (No. 1C1CMS331055-01-00).
About the Mount Sinai Health System
The Mount Sinai Health System is New York City's largest integrated delivery system, encompassing eight hospitals, a leading medical school, and a vast network of ambulatory practices throughout the greater New York region. Mount Sinai's vision is to produce the safest care, the highest quality, the highest satisfaction, the best access and the best value of any health system in the nation. The Health System includes approximately 7,480 primary and specialty care physicians; 11 joint-venture ambulatory surgery centers; more than 410 ambulatory practices throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and 31 affiliated community health centers. The Icahn School of Medicine is one of three medical schools that have earned distinction by multiple indicators: ranked in the top 20 by U.S. News & World Report's "Best Medical Schools", aligned with a U.S. News & World Report's "Honor Roll" Hospital, No. 12 in the nation for National Institutes of Health funding, and among the top 10 most innovative research institutions as ranked by the journal Nature in its Nature Innovation Index. This reflects a special level of excellence in education, clinical practice, and research. The Mount Sinai Hospital is ranked No. 18 on U.S. News & World Report's "Honor Roll" of top U.S. hospitals; it is one of the nation's top 20 hospitals in Cardiology/Heart Surgery, Gastroenterology/GI Surgery, Geriatrics, Nephrology, and Neurology/Neurosurgery, and in the top 50 in six other specialties in the 2018-2019 "Best Hospitals" issue. Mount Sinai's Kravis Children's Hospital also is ranked nationally in five out of ten pediatric specialties by U.S. News & World Report. The New York Eye and Ear Infirmary of Mount Sinai is ranked 11th nationally for Ophthalmology and 44th for Ear, Nose, and Throat. Mount Sinai Beth Israel, Mount Sinai St. Luke's, Mount Sinai West, and South Nassau Communities Hospital are ranked regionally.