The professor of emergency medicine at the University of Wisconsin-Madison School of Medicine and Public Health spoke about the challenges physicians face in the emergency department when dealing with patients that are cognitively impaired.
Manish Shah, MD, MPH
At the 2019 Alzheimer’s Association International Conference
held in Los Angeles, California, Manish Shah, MD, MPH, professor of emergency medicine at the University of Wisconsin-Madison School of Medicine and Public Health spoke with NeurologyLive
in an interview to discuss some of the challenges that occur in the emergency department when caring for patients that are cognitively impaired.
Shah explained that communication is the fundamental crux of care, especially in the emergency department, and while the electronic medical record has made it better, it’s not perfect. Ultimately the patient knows the type of care they want to receive and for those suffering from significant cognitive impairment, unless accompanied by a caregiver, health care practitioners are unable to have that conversation and know the patients’ goals of care, which may not necessarily be in the electronic health record.
To combat some of these challenges, physicians and health care providers are becoming much more focused on goals of care and the goals of patients. Another area that’s evolving is the concept of a geriatric emergency department. Spearheaded by the American College of Emergency Physicians, an accreditation program has been created for hospital emergency departments to meet specific criteria and standards in order to give older adults the best care possible.
NeurologyLive: Can you discuss some of the communication issues that you witness in the emergency department with patients who are diagnosed with dementia and their caregivers?
Manish Shah, MD, MPH:
I think it's a real challenge in the emergency department; so our patients come in, we don't necessarily have a lot of history on them, we don't know a lot of what's going on and if they can't provide us the basic information that we need about what's going on with their health, what their goals of care are, what their medications are, we really struggle at times.
The electronic medical record has made it a lot better, but it hasn't made it perfect, because ultimately the person knows what they want and particularly when you're talking about severe illnesses, we need to go to them to find out where do we want to take [their care], how aggressive do we want to be, how safe are they at home, if I feel comfortable sending them back home.
Communication is the fundamental crux of everything that we need to do and when a patient comes in with dementia we're really hamstrung unless we've got a caregiver, a friend, or a family member that can really help out to take care of these folks.
Do you find the biggest issue is centered around the EHRs being inaccurate and not well-kept, or is it that these patients aren't actually clinically diagnosed and they're coming to you and you're realizing that these people are significantly cognitive impaired?
I think it's a little bit of a lot of things. We don't identify a lot of people who are cognitively impaired in the emergency department—the literature is very clear that we don't do a great job identifying them. I think our challenge in taking care of these patients is a combination of we don't know if they're cognitively impaired, plus the data we need is not necessarily in the EHR. I think there's this myth out there that the EHR is the repository of all that is true and it's not necessarily correct because not everything goes in there.
Let's say we have this person who comes in who may have passed out or may have had some chest pain; if they're 50 years old, active, and healthy I may have a much more aggressive plan of care and they may want that and when we talk together about what the right approach is, that's what they would choose, but when [I see] someone who is maybe older, who has pretty significant dementia, I need to be able to have that conversation and know what their goals of care are and that may not be in the electronic health record all the time, and that's where we really struggle I think.
Where do you hope to see change to help ensure better care and outcomes?
I think one big piece that’s really starting to happen is that all physicians and health care providers are getting much more focused on goals of care and what patients want, and we're starting to see that in the health record from my personal experience more and more—as that evolves, I think it's going to make my life as an ER doctor much easier.
I think the other piece that’s really evolving is this entire concept of the geriatric emergency department; it's something that I think a lot of us have been advocating for for a long time. In the last couple years, between a number of foundations, the American College of Emergency Physicians, and the emergency departments in the hospitals, there's been a huge push to start hitting the standards that we've come up with that identify what makes the emergency department well structured and well organized to take care of older adults, and I think as this understanding permeates the emergency medicine world, which it totally is right now, we're going to be able to give better and better care to these folks.
Can you speak more to some of the trends we see in geriatric-focused care?
For the last 25 years or so there's been a pretty significant movement within the emergency medicine community to focus on how we can better care for the older adult. A few years ago a document came out that was supported by American Geriatric Society and all the emergency medicine societies, to say here are the guidelines that we feel--the evidence is somewhat limited--that would result in the best care possible for an older adult in the emergency department. From those guidelines, a couple of years ago we actually moved to an accreditation model that is really kind of spearheaded by the American College of Emergency Physicians, and hospital emergency departments come to us and try to get accredited at 1 of 3 levels, with the highest level obviously being the most intense and the greatest level of support for older adults and we have seen tremendous interest in this.
I'm on the Board of Governors for the accreditation program and I think we've accredited more than 70 hospital emergency departments in the first year, plus a large number of other hospitals that are in the process, and what this basically says is, kind of like the trauma or the stroke centers, these emergency departments are going to meet these certain criteria and standards in order to give older adults the best care possible, whether it is having easily accessible food and drink, having mobility devices, doing screening for potentially preventable conditions, or even having protocols in place to prevent iatrogenic injury, that's what this is all about. It's really been fulfilling and tremendous to watch this just blossom over the last number of years.
Is there a great deal of multidisciplinary coordination that occurs in that accrediation model at the highest level?
Multidisciplinary care is the crux of geriatrics care and that is embedded within every level of the geriatric emergency department accreditation, and at the highest level it absolutely involves everyone from social work to dietitians to physical therapists, occupational therapists, geriatricians, emergency physicians, and nursing. The way that the system is set up allows each hospital to react to their local needs and their local community needs rather than saying you've got to do it this one way only. Central to it is really very much how to work as a team to help these folks, and part of it is even how do you work to help patients after they go home? How is the connection to the primary care doctor, how is some of the other core components to improve communication and to focus on patient care and patient-level care?
Transcript has been edited for clarity.
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