Emergency Department Care

A.  One in five patients aged 65 to 74 years and one in four patients aged 75 years and older visit the Emergency Department (ED) each year (Albert et al., 2013).

B.  The ED is:

1.  The portal to other settings, including the hospital, long-term care, and mental health facilities (Samaras et al., 2010)

2.  Used for the performance of complex diagnostic workups, overflow, and off-hour medical care

3.  For some older adults, the only source of healthcare evaluation and treatment (Gonzalez Morganti et al., 2013; Stefanacci & Riddle, 2018)


A.  As compared to younger people, older adults:

  1. Have more diagnostic tests, longer stays in the ED, and are more likely to be admitted to the hospital (Banerjee et al., 2011)
  2. Are more likely to be readmitted on discharge from the ED; they also risk functional loss and higher rates of mortality (McCusker et al., 2007; Niska et al., 2010; Sklar et al., 2007)
  3. Are more likely to experience missed or incorrect diagnoses (Salvi et al., 2007), inadequate pain management (Hwang et al., 2010; Iyer, 2011), and less information (Baillie, 2005; George et al., 2006)


A.  Triage/primary assessment

  1. Delays in triage for older adults are associated with increased waiting time, anxiety, and discomfort (Miró et al., 1999), and increased risk for mortality (Perdue et al., 1998).
  2. Tools
    • The CTAS demonstrated high validity for older adults, which is especially useful for categorizing severity and for recognizing older adults who require immediate life-saving intervention (Bullard et al., 2008; Lee et al., 2011).
    • The ESI includes a comprehensive algorithm that describes symptoms and physiological indicators as well as the resources anticipated to be used (Gilboy et al., 2012). There are reports of under-triage using this tool when guidelines are not precisely followed (Platts-Mills et al., 2010).
  3.  A–B–C: identify and treat life-threatening conditions
    • Airway: challenges to establishing an airway include the presence of dentures, kyphosis, and cervical rigidity (Aresco & Stein, 2010).
    • Breathing and ventilation: consider age-related changes, including decreased pulmonary compliance, respiratory reserve, and arterial oxygenation (Blumenthal et al., 2010).
    • Circulation: use of antihypertensive medication may inhibit physiological response and/or mask signs of hypovolemic shock (Criddle, 2013).
  4. Consider atypical presentation and “red flags” (acute change on mental status and/or physical function, dyspnea, fatigue, self-neglect, apathy, and falls; Fletcher, 2004).

B.  Screen for risk for adverse outcomes: useful in guiding a plan to prevent avoidable complications during the ED stay, if admitted during hospitalization, and after an ED visit when transitioning to home or another setting

  1. TRST: is predictive of subsequent ED use, hospitalization, and NH admission (Meldon et al., 2003)
  2. ISAR: is predictive of increased risk for death, institutionalization, functional decline, and both repeat ED visit and hospital admission in the following 6 months after an ED visit (McCusker et al., 1999)

C.  General assessment

  1. History
    • Social history: living situation, marital status, work status, advance directives, supports within family and community, and stressors (Graf et al., 2011)
    • Past medical/surgical history: medication use, allergies, weight loss/changes in oral intake, and recent changes in diagnosis or medication regimens
    • Baseline cognition, mood, and physical function: early and sensitive indicators of physiological dysfunction (Ellis et al., 2014; Hare et al., 2008)
  2. Cognition and mood
    • Cognitive impairment: Geriatric Emergency Medicine Task Force recommends a mental status examination for older adults presenting to ED (Wilber et al., 2005).
      • Six-Item screener (Callahan et al., 2002)
    • Delirium: suggested by abrupt onset of cognitive impairment
      • Two-step process included in the Geriatric Emergency Department Guidelines Task Force (2014): delirium triage screen followed by the Brief Confusion Assessment Method (Han et al., 2013)
    • Depression: may interfere with clinical presentation and may be associated with greater number of ED visits (Meldon et al., 2003; Sanders, 2001)
      • ED-DSI: three-question screener (Fabacher et al., 2002)
  3. Physical function: recent loss often precedes the visit to the ED and can signify underlying illness (Wilber et al., 2006).
    • Basic ADL: Katz ADL index (Katz et al., 1963) or Barthel index (Mahoney & Barthel, 1965)
    • IADL: Lawton IADL Scale (Lawton & Brody, 1969)
  4. Medications:
    • ADEs: one-third are related to one of the following: warfarin, insulin, or digoxin (Budnitz et al., 2007).
    • PIMs: greater number is associated with frequent ED use (Wong et al., 2014).
    • Geriatric Emergency Department Guidelines Task Force (2014) recommendations:
      • Medication reconciliation
      • Screening for polypharmacy, PIMs, ADEs; collaborate with pharmacist and interdisciplinary team as indicated, and attending physician to correct.
  5. Falls: number one cause of nonfatal injuries in people older than 65 years treated in hospital EDs. (CDC, 2016)
    • ED evaluation
      • Assess for injury (consider occult presentation): complete physical examination; EKG; complete blood count; electrolytes; medication evaluation, including measurable levels; and appropriate imaging (Adhiyaman et al., 2002; Dominguez et al., 2005; Rathlev et al., 2006; Sterling et al., 2001)
      • Assess the cause of the fall (Mitchell et al., 2002; Sanders, 1999).
    • Targeted interview with patient and family: previous falls, location, activity, potential environmental factors, and symptoms preceding the fall
    • Comprehensive history and physical examination
      • Estimation of future fall risk: guided largely by determination of reasons for past falls (Carpenter et al., 2009)
  6. Substance misuse
    • Misuse defined: use of a drug for purposes other than that for which it was intended
    • Alcohol abuse: present in 14% of older adults presenting to the ED
      •  Screening tool: Alcohol Use Screen and Assessment in Older Adult has been shown to have good-to-excellent sensitivity and specificity (Ong-Flaherty, 2012).
    • Evaluation (Center for Substance Abuse Treatment, 1998)
      •  Patient’s social network: identify which members are supportive of treatment and which members are potentially hazardous to the patient. Harmful network members include active substance abusers; those who “enable” the patient’s misuse; and those who abuse the patient physically, sexually, or emotionally.
      • Patient’s mood, cognition, sleep patterns, and mental health history, including past treatment, should also be ascertained.
      • It should also be verified that the patient has adequate housing and access to food, adequate transportation, and medical care (Ross, 2005).
      • When there is evidence of substance misuse, nursing interventions focus on (a) monitoring for withdrawal; (b) providing an environment that is safe from potential harms to patient; (c) collaborating with the patient, family, physician, and social worker to secure a mental health evaluation and program directed to the substance abuse needs and support.
      • Careful handoff should include the communication of the patient’s history and clinical findings as well as safety issues, including fall risk and the presence of delirium.
  7. EM
    • Definition: physical, verbal, sexual, and psychological abuse, as well as abandonment, exploitation, and neglect (Acierno et al., 2010)
    • Nurse is expected to know the organization’s policies for reporting suspected EM, as required by The Joint Commission on Accreditation and state mandatory reporting requirements (Dong, 2012; Falk et al., 2012).
    • Red flags of EM: delays in seeking treatment; signs of withholding or giving too much medication; missed appointments; use of several hospitals; driving to a hospital farther away from home; description of an event that does not fit the injury sustained; repetitive injuries (Heath & Phair, 2009); and signs of caregiver indifference, berating or threatening comments, hypervigilant/possessive behavior, or excessive concerns over finances warrant suspicion of EM (Bond & Butler, 2013; Stiegel et al., 2007)
    • When EM is suspected:
      • Separate the older adult from the caregiver and obtain a detailed history and physical assessment; interviewing the patient about his or her feelings of safety is an important screening question (Bond & Butler, 2013).
      • Conduct a careful medical history, including baseline conditions, and a comprehensive physical examination.
        • Physical examination cues may include poor hydration; poor hygiene; suspicious injuries in unusual locations and bruises in various stages of healing; and unexplained abrasions and/or markings on skin, including human bite marks, skin tears, pressure ulcers, or genital complaints, including infections or injury (Stiegel et al., 2007).
        • Follow mandatory reporting procedures.


A.  Delirium and dementia

  1. Preventing delirium
    • Control the environment:
      • Support the family/familiar person (or volunteer) present with the patient.
      • Provide sensory aids (glasses and hearing aids, and offer hearing amplifiers and magnifiers as indicated).
      • Control noise.
      • Avoid excessively bright lights when possible.
      • Provide comfort measures, including fluids and a warm blanket.
    • Additional nursing interventions include promoting mobility and addressing the need for pain management, toileting, rest/sleep, and fluid/hydration (Hshieh et al., 2015; Rivosecchi et al., 2015).
  2. Managing delirium: in addition to interventions aimed at reversing the cause:
    • Continue to provide aforementioned supportive measures.
    • Avoid physical and chemical restraints (American Association of Critical Care Nurses, 2011).
    • Educate patient/family about the etiology of delirium and interventions.
    • Involve family in promoting safety and comfort for the patient (Boltz et al., 2014, 2015).

B.  Prevention of falls and related injuries

  1. Collaborate with the interdisciplinary team to modify fall risk (e.g., correct orthostasis, remove offending medications, etc.; Alexander et al., 2013).
  2. Provide close oversight (Capezuti et al., 2002).
  3. Encourage physical activity (e.g., range of motion).
  4. Pay attention to toileting (Alexander et al., 2013; Capezuti et al., 2002).
  5. For the person who is at risk for injury caused by cognitive impairment, weakness, and low mobility, provide low beds with bedside mats (Capezuti et al., 2002).

C.  Prevention of pressure ulcers

  1. The use of pressure-redistributing foam mattresses has shown to be a cost-effective approach to prevent ED-acquired pressure ulcers (Pham et al., 2011).
  2. The use of reclining chairs in the ED instead of ED gurney beds has been shown to reduce pain and improve patient satisfaction (Wilber, Burger, et al., 2005).
  3. Evidence-based guidelines to prevent and manage pressure ulcers should be followed, including skin assessment, pressure relief/off-loading, prevention/treatment of infection, pain control, and nutritional evaluation and management (Ayello, 2011; Reddy et al., 2006).

D.  Prevention of CAUTI

  1. Definition: a UTI that occurs while a patient has an IUC or within 48 hours of its removal.
  2. Preventive practices
    • Avoid unnecessary urinary catheter use (Apisarnthanarak et al., 2007; Fink et al., 2012; Hooton et al., 2010; Saint et al., 2013).
    • Consider removal prompts and nurse-initiated urinary catheter discontinuation protocols (Fink et al., 2012).
    • Use an aseptic technique and sterile products during catheter insertion; maintain cleanliness (Oman et al., 2012; Saint et al., 2013).
    • Handoff: communicate plan/need for surveillance and for the earliest removal (Wald & Kramer, 2011).


A.  Problem: misinformation (Steiner et al., 2010)

  1. Primary source of older adults’ dissatisfaction with ED care
  2. Contributes to readmission

B.  Factors associated with misinformation include underrecognition of cognitive dysfunction, lower health literacy, and financial impediments for prescriptions and recommended outpatient follow-up (Baraff et al., 1992; Carpenter et al., 2014; Han et al., 2011).

  1. Three systematic processes to ensure appropriate transfer of information to patient/family and providers (-Geriatric Emergency Department Guidelines Task Force, 2014):
    • Discharge planning
      • Components: (a) evaluation of the clinical status related to the admitting problem, (b) assessment of physical and psychosocial functional status (including fall/safety risk), (c) risk assessment for subsequent functional decline (e.g., ISAR or TRST), (d) assessment of caregiver availability and ability, (e) an appraisal of the patient/family readiness and ability to learn, (f) medication review, (g) review of advance directives, and (h) referrals with follow-up arrangements (AHRQ, 2009; CMS, 2014)
      • Patients and families prefer active engagement and a range of options will support the patient’s preferences and goals (Popejoy, 2011).
      • CMS (2014) recommends that EDs maintain a file of appropriate community-based services, supports, and facilities to which the patient can be referred.
    • Patient/family education
      • Challenges to patient/caregiver understanding are limited literacy and numeracy (Ginde, Clark, et al., 2008; Ginde, Weiner, et al., 2008).
      • Print discharge instructions are often not written at appropriate reading levels (Jolly et al., 1993; -Williams et al., 1996).
      • To address challenges (Geriatric Emergency Department Guidelines Task Force, 2014):
        • Written instructions should be at the appropriate grade level (established using a literacy calculator).
        • Use plain language, focusing on “need-to-know” information, limiting the documents to essential content in order to avoid information overload (McCarthy et al., 2012).
        • Information and educational material should be provided in large font suitable for older adults
        • Use the teach-back method (Schillinger et al., 2003; Slater et al., 2013).
        • Use a standardized tool that assesses older adults’ ability to self-administer medication such as the DRUGS. This tool requires subjects to perform the following four tasks with each of their medications: (a) identify the appropriate medication, (b) open the container, (c) select the correct dose, and (d) report the appropriate timing of doses (Edelberg et al., 2000; Kripalani et al., 2006)
    • Handoff
      • Recommended standardized information (Geriatric Emergency Department Guidelines Task Force, 2014) to provide cross-settings:
        • Presenting complaints
        • Test results and interpretation
        • ED therapy and clinical response
        • Consultation notes (in person or via telephone) in ED
        • Working discharge diagnosis
        • ED physician note, or copy of dictation
        • Patient condition (including fall risk, functional and cognitive status)
        • New prescriptions and alterations with long-term medications
        • Discharge recommendations: physical activity, diet, resources/services
        • Support systems
        • Advance directives
        • Follow-up plan
      • Additional approaches: (a) a verbal report from ED nurses provided to the NH as well as written documentation; (b) an emergency form in NH residents’ charts that contains predocumented information with an area to write in the reason for transfer; (c) brief NH-to-ED and ED-to-NH transfer forms that are accepted and used by local NHs and EDs (Terrell & Miller, 2006); (d) structured data-sharing (Vollbrecht et al., 2018); and (e) INTERACT tools: checklist of key transfer documents, lists of critical data for interfacility communication at the time of transfers, a medication reconciliation form, and transfer forms (J. G. Ouslander et al., 2014).
    • Follow-up (Kessler et al., 2013)
      • Telephone follow-up for patients discharged from the ED
      • Home visits provided to high-risk individuals
      • Telemedicine alternatives when indicated, especially in rural areas


A.  Improved patient/family satisfaction and experience

B.  Processes:

  1. Adherence to evidence-based practice and guidelines
  2. Throughput and waiting times

C.  Better clinical outcomes, such as fewer falls, pressure ulcers, and hospital-acquired infections, as well as improved diagnostic accuracy

D.  Improved organizational outcomes: readmission rates (ED and hospital) and cost

E.  Enhanced staff competencies and satisfaction


A–B–C        Airway–breathing–circulation

ADE            Adverse drug events

ADL            Activities of daily living

CAUTI        Catheter-associated urinary tract infection

CMS            Centers for Medicare & Medicaid Services

CTAS          Canadian Triage and Acuity Scale

DRUGS      Drug Regimen Unassisted Grading Scale

EM              Elder mistreatment

ESI              Emergency Severity Index

IADL          Instrumental activities of daily living

ISAR           Identification of Seniors at Risk

IUC             Indwelling urinary catheter

NH              Nursing home

PIMs            Potentially inappropriate medications

TRST           Triage Risk Screening Tool

UTI              Urinary tract infection


Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Chapter 44:  Arendacs, R., & Boltz, M. (2021) Care of the Older Adult in the Emergency Department.    In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 847-870).   New York: Springer.


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