Geriatric Emergency Medicine: Soliciting feedback from the forum

[Dane07MD]

Hello friends! Seeking some input and/or information regarding your ED observation units, if you've got them.

I'm going to be starting as the geriatric emergency medicine fellow next year at my institution. There exist only 5 of these across the country and without ACGME accreditation or certification, there is plenty of variability in the curricula. I myself am the first fellow at our hospital, and have been given a fair bit of freedom to construct my own curriculum. It encompasses administrative aspects, palliative care, geriatric medicine (just more troponins and CTs, right?), and successful operation and construction of an ED observation unit. Shockingly, our level 1 trauma and academic medical center does not currently house an observation unit, so that will be a unique opportunity for me to learn and build one from the ground level.

My question is this: for those of you out there who work in an ED with an obs unit, what typically is being sent to the obs unit that doesn't necessarily need to go to the floor under the care of the hospitalist. There has been much discussion about what should and shouldn't go to an ED obs unit. Arguably (as Slovis said in one of his ACEP talks this year), the ED is faster, better, and more efficient at doing many things, including workups that previously may not have been done in the ED. Syncope is a good example of this. Syncope work up (Echo, ultrasound, 23 hr tele monitor) can be done faster and cheaper in the ED these days. Other things that seem suitable for an ED-obs unit are cellulitis (marking pen and IV abx for 23 hours), low risk chest pain risk stratification, short stay overnight for specialist studies such as GI scope the next day, a temporary place for an older patient who shouldn't go back to their SNF at 3am but doesn't need to take up a hospital bed. These are just a few examples...

What are you guys putting in your obs units and what specifically are you NOT putting in there anymore because it became a problem within your specific system.

Feel free to post or just private message me on the matter. Thanks for the time and consideration!

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[EMIM2011]

chest pain for rule out + stress test or cardiology consult, TIA, syncope, cellulitis, "stable" asthma, "stable" pyelo, "stable" DKA, anyone awaiting imaging studies with a significant delay (e.g., MRIs)

 

[dotcb]

Obs unit-

Yes:
COPD, asthma, low risk chest pain (6 hr trop +/- stress test), cellulitis, pyelonephritis, recurrent abd pain/N/V, people awaiting social work or PT eval for disposition, patients with explained recurrent anemia who are receiving a blood transfusion, people with a finite endpoint and a clear plan (Ex. elevated creatinine felt to be dehydration - getting 2L NS and a repeat BMP - if improved -> DC, if not, admit).

No:
prisoners, psychiatric patients (uncontrolled mental illness or documented history of physical or verbal aggression), syncope (unless someone is watching the tele), CHF (needs specialist med titration), anyone unstable.

 

[RustedFox]

Geriatric EM Fellow ?

Sweet. I totally dig geriatrics; did an elective month with the geri-fellows at my residency.

Hell; come on down to Florida; my average patient is a 72 year old female with eight comorbidities.

I have no obs units at any of my present job-sites; but wanted to post with some encouraging words for yah. Good luck, amigo!

 

[Dane07MD]

Thanks man. Certainly doesn't sound intriguing to most people, especially adrenaline guided EM docs, but figured it was interesting, and probably applicable down the line as our generation continues to age. With ACEP now having "geriatric ED guidelines" there's plenty of stuff to be done and plenty of EDs to reform if I feel so inclined. Plus, need something to fall back on once the wick begins to burn out in a couple decades.

 

[Birdstrike]

Thanks man. Certainly doesn't sound intriguing to most people, especially adrenaline guided EM docs, but figured it was interesting, and probably applicable down the line as our generation continues to age. With ACEP now having "geriatric ED guidelines" there's plenty of stuff to be done and plenty of EDs to reform if I feel so inclined.

Interesting. Good for you. It may be come an accredited subspecialty as some point and then you'll be fast tracked to grandfather in. Anything you can do to get a niche, gives you a leg up, as far as I'm concerned. In fact, you might want to start pushing ABEM to think about accreditation for this, as that could only help you in your career path, and help the specialty also. Good work.