The Centers for Medicare & Medicaid Services recently introduced 2 clinical quality measures that intend, in part, to disincentivize hospital boarding: a patient safety concern that involves holding admitted patients in the emergency department while an inpatient bed is unavailable. The Age-Friendly Hospital Measure (AFHM), a structural measure, asks hospitals to attest to having protocols in place to reduce boarding for older patients. The Emergency Care Access and Timeliness (ECAT) measure, an intermediate outcome measure, will require hospitals to report on the proportion of boarded patients. Each measure was developed under a different parent quality reporting program-1 inpatient and 1 outpatient-which has the unintended consequence of producing meaningful variation between the measures. We describe opportunities to standardize and synergize the AFHM and ECAT to capture the prevalence of boarding uniformly, prevent gamesmanship, and enhance their impact on hospital performance. In particular, we highlight the importance of stratifying ECAT by the older-adult patient population to complement AFHM and since older adults are uniquely vulnerable to boarding and its associated safety risks.

INTRODUCTION:More than half of older adults with Alzheimer's Disease and Related Dementias (ADRD) are undiagnosed, limiting timely access to person-centered care. Therefore, clinicians, researchers, and population health managers need scalable, reproducible approaches to monitor both prevalence and diagnostic gaps. We evaluated whether a decision-analytic modeling framework can translate a limited number of clinician-adjudicated cases of ADRD into a probabilistic computational phenotype for accurate, population-level assignments of probable ADRD in the emergency department (ED) setting using routinely collected electronic health record (EHR) data. METHODS:Retrospective cohort study of 5000 adults aged ≥ 65 years from nine EDs within a large integrated health system (2014-2022). We randomly selected 500 individuals for clinician adjudication of dementia status (reference cohort), reserving the remaining 4500 as a phenotyping cohort. We developed the phenotype as a logistic regression model trained on adjudicated cases, embedding pattern-mixture multiple imputation to address information bias. We applied decision-curve analysis to evaluate clinical utility across probabilistic thresholds. We applied the phenotype to assign dementia status to 4500 unadjudicated patients and compared clinical characteristics to adjudicated cases. RESULTS:The mean (SD) age was 77.4 (9.0) years; 55.4% were women; 102 individuals (20.4%) had clinician-adjudicated ADRD. The model demonstrated good discrimination (AUROC 0.87; 95% CI 0.82-0.91). Decision-curve analysis revealed net clinical benefit across examined thresholds (predicted probabilities 12%-32%), identifying an additional 16-18 probable ADRD cases per 100 older adults. Among those without ADRD-related diagnosis codes, net benefit ranged from 8 to 13 additional correct identifications per 100. Phenotype-assigned cases closely resembled clinician-adjudicated cases (standardized mean differences ≤ 0.20). CONCLUSIONS:A probabilistic computational phenotype derived from routinely collected EHR data accurately reproduced clinician-adjudicated ADRD status and demonstrated net clinical benefit, including among ED patients whose ADRD was not captured by diagnosis codes. Adoption of this replicable framework may enable healthcare organizations to strengthen ADRD surveillance and reduce underdiagnosis.

BACKGROUND:Since 2018, the Geriatric Emergency Department (GED) Accreditation Program has recognized Emergency Departments (EDs) that provide high-quality care tailored to older adults. GEDs have expanded rapidly across the United States in recent years, but little is known about how GED care is associated with patient outcomes, including hospital admissions and subsequent mortality. METHODS:We used the 2018-2021 Health and Retirement Study (HRS)-Medicare linked data of adults aged ≥ 65 years. We supplemented these data with the American College of Emergency Physicians (ACEP) GED accreditation list and American Hospital Association (AHA) data. Receipt of acute care in a GED was defined as having an ED visit at a GED. Patient-level analyses were conducted using each individual's most recent ED visit. Multivariable logistic regression models were used to estimate associations between receipt of acute care in a GED and outcomes of hospital admission and 30-day mortality, adjusting for patient demographics, socioeconomic status, health conditions, ED visit severity, and hospital-level characteristics. RESULTS:Among 4563 older adults who had an ED visit, 270 (5.9%) received acute care in GEDs and 4293 (94.1%) received non-GED care. Compared with those treated in non-GEDs, patients treated in GEDs had significantly lower odds of hospital admission (OR, 0.61; 95% CI, 0.42-0.87; p < 0.01) and 30-day mortality (OR, 0.62; 95% CI, 0.40-0.96; p < 0.05). Subgroup analyses showed that the association with admission was more pronounced among adults aged 65-80 years (OR, 0.43; 95% CI, 0.24-0.76; p < 0.01) and non-Hispanic White individuals (OR, 0.51; 95% CI, 0.34-0.78). An association with lower mortality was observed among non-Hispanic White individuals (OR, 0.51; 95% CI, 0.30-0.87; p < 0.05). CONCLUSIONS:GED care was associated with lower odds of hospital admissions and 30-day mortality among older adults. Broader implementation may expand the reach of GED programs across diverse populations.

STUDY OBJECTIVES:To compare end-of-life predictions as measured by the physician-answered surprise question (SQ), "Would you be surprised if this patient died in the next 6 months?"), the Geriatric End-of-Life Screening Tool (GEST) artificial intelligence (AI) model, and a new collaborative GEST+SQ model for predicting 6-month mortality in older emergency department (ED) patients. METHODS:This was a single-site prospective cohort study (Nov 2022 to June 2023) at a tertiary academic ED of patients aged 65 years and older. Answers to the SQ were collected within the electronic health record at ED disposition and GEST scores were calculated from available records using laboratory, vital signs, demographic and historical data. Six-month mortality was adjudicated via electronic health record and state records. SQ and GEST were compared using sensitivity and specificity. A new logistic regression model was developed combining SQ and GEST (GEST+SQ) and compared with GEST alone, using area under receiver-operating characteristic curves (ROC-AUC) for discrimination and expected calibration error for calibration. We modeled a sequential screening pathway where low- and high-risk patients received only GEST screening, whereas intermediate-risk patients received both GEST and SQ, reporting the proportion of patients for whom adding the SQ to GEST would change a theoretical referral to intervention. RESULTS:From 9,256 eligible patients, 3,479 had SQ responses (37.6%), with 13.3% 6-month mortality. When matching GEST sensitivity to SQ (83.8%), GEST had greater specificity than the SQ (61.5% [56.7 to 67.1] vs. 50.8% [49.1 to 52.6]). At matching specificity (50.8%), GEST sensitivity (90.0% [87.0 to 92.7]) exceeded the SQ (83.8% [80.3 to 87.0]). GEST had an receiver-operating characteristic - area under the curve (ROC-AUC) of 0.79 (0.77 to 0.81), whereas the GEST+SQ model had ROC-AUC of 0.80 (0.78 to 0.82). The GEST+SQ model had significantly improved expected calibration error of 0.01 (0.01 to 0.02) for GEST+SQ vs. 0.042 (0.03 to 0.05) for GEST alone. In a sequential screening pathway, as few as 5% of patients required SQ screening following GEST risk scoring. CONCLUSION:GEST modestly outperformed the SQ for predicting 6-month mortality. A GEST+SQ collaborative model did not improve discrimination (ROC-AUC) over GEST alone, but improved calibration. Sequential screening using GEST and then the SQ for intermediate-risk patients could decrease physician screening burden by 95% relative to manual, SQ-only screening. Collaborative approaches integrating automated tools with targeted physician input may enhance ED mortality risk assessment while reducing clinician effort.

OBJECTIVES:Older adults with abdominal pain present diagnostic uncertainty due to less informative histories/exams, broader etiologies, and higher morbidity. Whether ED imaging decisions are calibrated to this risk is unclear. The objective of this study was to compare age-stratified clinical features, CT utilization, and CT diagnostic yield, and to assess how history/physical and clinician pretest suspicion relate to adverse outcomes. METHODS:This was a retrospective cohort analysis of data from a prospective cohort collected from March 2016-January 2017 at a single community teaching hospital emergency department in southwest Baltimore. We analyzed 1169 visits of adults presenting with nontraumatic abdominal pain including 229 (19.6%) aged ≥ 60 years. Patients < 18 years were excluded. Age groups were 18-39, 40-59, ≥ 60 years. Outcomes were CT ordering, acute actionable CT findings, admission, surgery, and a composite of adverse outcomes (any actionable CT finding, admission, surgery, or Emergency General Surgical diagnosis). History and physical examination operating characteristics (e.g., sensitivity/specificity of tenderness, rebound) were also calculated. RESULTS:Of 1169 visits, 19.6% were aged ≥ 60 years. CT ordering increased with age (41.7%, 66.2%, 70.7% for 18-39, 40-59, ≥ 60; p < 0.001), as did CT yield (18.4%, 31.2%, 37.7%; p < 0.001). Admissions (12.1%, 28.0%, 37.6%) and surgeries (4.6%, 9.0%, 10.6%) also rose with age. Clinician pretest suspicion was similar across age groups. Abdominal tenderness was less sensitive for adverse outcomes in older adults (sensitivity 0.58 in ≥ 60 vs. 0.73 in 18-39 and 0.73 in 40-59), while rebound tenderness was highly specific across ages (specificity 0.98, 0.96, 0.98). The number of potential diagnoses to consider rose with age. CONCLUSION:In this cohort, CT use and positivity increased with age and key exam findings (e.g., tenderness) being less informative in older adults, despite similar reported clinician pretest suspicion. These results support age-aware imaging decisions and motivate reframing ED abdominal pain as a geriatric-specific chief complaint.

This study examines the patient- and hospital-level variation in time to initiation of inpatient management among patients admitted to general medical services.

STUDY OBJECTIVE:Emergency department (ED) visits among older adults represent critical transition points in health care, often resulting in substantial downstream utilization. We aimed to quantify health care contact days in the 30 days following a treat-and-release ED visit among older adults and examine associations with demographic and clinical characteristics. METHODS:We conducted a pooled cross-sectional analysis of 2016-2021 Medicare Current Beneficiary Survey data. The sample included treat-and-release ED visits among beneficiaries ≥ 65 years. Health care contact days were categorized as institutional (ED, hospital, skilled nursing facility, hospice) and ambulatory (outpatient visits, labs, imaging, procedures, or treatments). We applied zero-inflated Poisson regression to estimate the likelihood and intensity of health care contact. RESULTS:The analytic sample comprised 10,964 treat-and-release ED visits. Within 30 days, 22.5% of visits resulted in institutional contact and 84.4% in ambulatory contact. On average, each ED visit was followed by 4.3 total contact days (3.0 ambulatory, 1.3 institutional) within 30 days. Having ≥ 2 chronic conditions was associated with greater odds of both institutional (OR: 1.46, 95% CI: 1.28-1.66) and ambulatory contact (OR: 1.44, 95% CI: 1.25-1.66). Dementia was associated with reduced odds of ambulatory contact (OR: 0.51, 95% CI: 0.37-0.72). CONCLUSIONS:Older adults experience frequent and sustained health care contact following treat-and-release ED visits, with particularly high intensity among those with multi-morbidity. Reduced ambulatory follow-up among patients with dementia highlights a potential gap in care coordination after ED discharge.

ABSTRACT Background Three San Francisco health system emergency departments have developed Geriatric Emergency Department (GED) models of care programs supporting and providing care for emergency department (ED) patients at risk for or living with dementia. Each system recognized: 1) the high proportion of older adult ED patients and those at risk for dementia, 2) the need to identify cognitive impairment in older adult ED patients, 3) the importance of developing approaches to connect older adult ED patients and their care partners with resources and diagnostic specialty services. Methods We describe how each hospital adopted and implemented pragmatic GED models of care to support and improve care for ED patients at risk or living with dementia. We also report the proportion of ED encounters made by patients with dementia histories and the number of these reached by GED programs. Results Three San Francisco hospitals (a tertiary care, critical access, and large integrated health system-community ED) independently implemented GED programs to support and enhance emergency care for patients living with dementia. Each uses screening and assessment tools to identify patients at risk for cognitive impairment. Each captures screening and assessment data to facilitate care and resources for post-discharge care, ensuring coordinated transitions and support for older adults. Programs varied by target patient population age and staff and resource allocation to support program goals. Site-specific pathways differed by location, patient populations, and support from geriatrics, emergency medicine, palliative medicine, neurology, psychiatry, pharmacy, referral processes, and/or pastoral care. Conclusions Developing GED care interventions that facilitate care for patients at risk of or living with dementia is possible and sustainable when the pathway aligns with health system leadership goals through persistent value demonstration, communication, and promotion. Ultimately, developing and disseminating models of GED care is designed to address geriatric syndromes inclusive of dementia care through continuous quality improvement. KEY POINTS This paper demonstrates the feasibility of implementing Geriatric ED programs with targeted support for people living with or at risk for dementia across three distinct health systems in San Francisco. We describe the reach and implementation processes of each program including commonalities, differences, challenges faced, and opportunities for future improvement. Creating unique care pathways for older adults and those with cognitive impairment in the emergency department (ED) is often guided by health system resources. Assessing cognition and identifying potential dementia is feasible during an ED visit. An interprofessional approach to geriatric ED care is essential to sustainability and success.

Objective Evaluating geriatric emergency department (GED) interventions requires accurate longitudinal identification of GED sites and reliable linkage to hospital-level data, yet identifiers are often incomplete, inconsistent, or change over time. Our objective was to construct longitudinal GED identifiers by reconciling publicly available GED accreditation lists in the United States (US) linked to hospital characteristics in the American Hospital Association (AHA) survey. Approach GED accreditation lists were first affirmed as GEDs and newly accredited GEDs using a two-stage fuzzy matching approach blocked by state. Sites were initially matched using hospital name similarity (distance ≤ 0.15), followed by city-based matching for remaining unmatched sites (distance ≤ 0.10). GEDs were then linked 1:1 to the AHA survey by manually assigning the AHAID using name and city. Discrepancies were resolved through multi-reviewer adjudication informed by geographic context, producing a curated reference linkage set of GEDs. In parallel, an XGBoost classifier paired GED sites with AHA hospitals in the same state using similarity features (name, city, teaching, rurality, and year difference) to independently reproduce curated linkages. Results Among 545 US GEDs between 2018-2025, 482 had AHAIDs and 63 were missing. XGBoost reproduced 90% (95% CI: 87.8-92.5%) of curated linkages, with name similarity and city agreement accounting for over 85% of model importance by gain. Common challenges included name changes, system-level identifiers spanning multiple campuses, and accreditation turnover (sites gaining or losing accreditation). Conclusions Accurate GED-AHA linkage is achievable, though sensitive to identifier instability, naming variation, and longitudinal changes.

INTRODUCTION:Emergency department (ED) care transitions are particularly challenging for persons living with cognitive impairment (PLWCI) and their care partners. Existing measures overlook care partners' unique experiences. We developed and validated the Caregiver-reported Outcome Measure for Emergency care Transitions (COMET) tool to assess these transitions. METHODS:We enrolled 170 care partners from four EDs in a multiphase process including qualitative interviews, item development, member checking, cognitive debriefing, expert review, and psychometric testing. RESULTS:The final 15-item COMET tool captures understanding of discharge instructions, caregiver burden, and positive aspects of caregiving. It showed feasibility (mean completion time = 5.87 min), excellent internal consistency (α = 0.89, ω = 0.99), and good test-retest reliability (r = 0.85). Factor analysis supported a clear structure, and correlations with the Care Transitions Measure-3 supported validity. DISCUSSION:COMET is a feasible, reliable, and valid tool for evaluating ED care transitions for PLWCI and their care partners.

This cross-sectional study identifies the prescribing rate and most commonly prescribed classes of potentially inappropriate medications for older patients at emergency department discharge.

BACKGROUND:Caring for a person living with dementia (PLWD) can place significant psychological and physical strain on family caregivers, making caregiver burden a critical concern amid the increasing global prevalence of dementia. While many studies have focused on resources to support caregiving or care-seeking patterns of PLWD, few have examined caregivers' own healthcare utilization. We sought to characterize emergency department (ED) visit use among family caregivers of PLWD. METHODS:We performed an observational cohort study using the 2016 to March 2020 Medical Expenditure Panel Survey data. We identified PLWD based on ICD-10 codes and caregivers through specified relationships to the reference PLWD. The primary outcome was the rate of monthly ED visits among PLWD family caregivers (cases) compared to matched MEPS participants not caring for PLWD family members (controls), using a 1:1 propensity score matching approach to adjust for caregiver age, gender, race, education, and health conditions. We determined risk ratios between groups to account for differences in follow-up time and quantify differences in ED visit rates. RESULTS:The analytic sample included 510 participants, comprising 255 cases and 255 controls - 54.7% were female, 49.8% were White, and the average age was 45.5 years old. Aggregated across all study years, PLWD caregivers had 4.57 ED visits/100 person-months, while matched controls had 3.51 ED visits/100 person-months, representing a 30% higher rate of ED visits for PLWD caregivers (95% CI: 1.02, 1.66) compared to controls. CONCLUSION:Caregivers of PLWD have higher ED visit rates than matched controls not caring for family members with dementia. These findings highlight the potential healthcare challenges faced by dementia caregivers and emphasize the need for targeted interventions and policies to support their health and well-being.

The original consensus-based Geriatric Emergency Department (GED) Guidelines, published in 2014, established a framework of core principles for delivering high-quality, age-appropriate emergency care for older adults. In response to significant advances in geriatric emergency medicine research and evolving clinical priorities, we developed the GED Guidelines 2.0 to ensure continued relevance, clinical utility, and evidence-based rigor. This concept paper describes the systematic and iterative process undertaken to update the guidelines, including the formation of multidisciplinary working groups and the application of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Unlike the original GED Guidelines, our approach prioritized methodological transparency, formalized evidence grading, and consensus building grounded in systematic reviews and meta-analyses. We describe the identification, recruitment, and collaboration of multidisciplinary clinical and academic experts working together to improve the care of older adults in the emergency department. Through this multidisciplinary effort, key geriatric domains were selected, priority topics identified, and systematic reviews and meta-analyses conducted to generate a robust evidence base for future guideline and policy development. The GED Guidelines 2.0 represents the first emergency medicine (EM) subspecialty guideline effort to fully adopt the GRADE framework, offering a novel blueprint for future EM guideline development.

Since 2018, the Geriatric Emergency Department (GED) accreditation program has recognized EDs that provide high-quality care tailored to older adults. Despite its considerable expansion in recent years, no studies have evaluated the impact of GED care on patient-centered outcomes using national data. Our objective was to determine whether GED care is associated with improved outcomes among older adults. We used the 2018-2021 Health and Retirement Study-Medicare linked data of adults aged≥65 years, weighted for national estimates. Receipt of GED care was defined as having an ED visit at a GED (versus not). Patient-level analyses were conducted using each individual’s most recent ED visit. Multivariable logistic regression models were used to estimate associations between receipt of GED care and outcomes of hospital admission and 30-day mortality, adjusting for patient demographics, socioeconomic status, health conditions, and hospital-level characteristics. Among 4,570 older adults – representing 25,317,444 adults nationally – with an ED visit, 270 (5.9%) received GED care. Compared with those treated in non-GEDs, patients treated in GEDs had significantly lower odds of hospital admission (OR, 0.710; 95% CI, 0.505-0.998), primarily among adults aged 65-80 years (OR, 0.565; 95% CI, 0.336-0.952) and non-Hispanic White individuals (OR, 0.614; 95% CI, 0.410-0.920). Among non-Hispanic White individuals, GED care was also associated with a significant reduction in 30-day mortality (OR, 0.554; 95% CI, 0.324-0.945). This is the first study using national data to demonstrate that GED care significantly improves outcomes for older adult subgroups. Broader implementation can enhance reach and impact across programs and diverse populations.

Older adults use the emergency department (ED) as an important source of acute medical care, making 20+ million visits annually. Persons living with dementia are twice as likely to use the ED and 1.5 times more likely to have an avoidable visit. When in the ED, they often struggle with the fast-paced setting and may not be able to give a complete medical history. These challenges, along with other adverse events, put patients with dementia at greater risk for poor outcomes. Yet emergency care for older adults is suboptimal, and care is especially poor for older adults with dementia, even though these adults seek ED-based care more regularly than matched controls. Three decades of research has shown that dementia is under-recognized in emergency departments, despite a proliferation of screening tools. Under-recognition of dementia in the ED leads to under-recognition in inpatient services, which has broad-reaching consequences, such as longer hospital stays, lower patient satisfaction, accelerated cognitive declines, and increased health care costs. Better detection of dementia may improve the ED staff’s ability to implement interventions that can reduce the rate of cognitive decline and improve care coordination and patient safety. This session will review the literature of current and past dementia detection approaches and discuss top research questions generated by the patients, care partners and members of the transdisciplinary GEAR Detection Work Group.

Abstract INTRODUCTION Patients with dementia and their care partners commonly experience poor communication and fragmented care transitions after emergency care. With these challenges likely amplified in non–English‐speaking populations, this study aimed to examine the emergency department (ED) discharge experiences of Hispanic patients with cognitive impairment. METHODS We conducted recorded, semi‐structured interviews of 10 dyads (patient and an identified care partner) 1 week after ED discharge. Team members coded professional transcriptions in accordance with the National Quality Forum Emergency Department (NQF ED) Care Transitions Framework and identified themes. RESULTS Three priority themes emerged among the Hispanic population: (1) Enhancing communication and discharge processes, (2) trust deficits impacting their readiness and safety, and (3) families as primary care coordinators navigating systemic inefficiencies. DISCUSSION Findings highlight the importance of culturally tailored discharge processes, shared decision‐making, and strategies addressing language barriers to improve ED care transitions for Hispanic patients with dementia.

ABSTRACTBackgroundExisting risk scores assessing geriatric vulnerability in the emergency department (ED) have shown limited predictive power, especially in diverse populations. We investigated the relationship of a quick and easy‐to‐administer geriatric vulnerability scoring system with functional decline and mortality in older patients admitted to multiple hospitals through the ED in the United States (US) and Brazil (BR).MethodFederated, international, multicenter observational study of hospitalized ED patients aged ≥ 65 from US and BR. The six criteria from the PRO‐AGE score (Physical impairment, Recent hospitalization, Older age [≥ 90], Acute mental alteration, Getting thinner, and Exhaustion; 0–8; higher scores = greater vulnerability) were assessed on admission. We used proportional hazards models to investigate the relationships between PRO‐AGE score groups and 90‐day mortality and functional decline, defined as new dependence in activities of daily living (ADL) and instrumental ADL (IADL), after adjusting for age, sex, race and ethnicity, education, Charlson comorbidity score, and study site. Death was considered a competing event for the functional decline outcome.ResultsA total of 1390 patients were included (US = 560; Brazil = 830). The 90‐day risk of death was higher for the upper compared with the lower (reference) PRO‐AGE group in both cohorts (US: HR = 11.76; 95% confidence interval [CI] = 2.56–54.04; BR: HR = 12.29; 95% CI = 3.54–42.59), whereas the risk of new 90‐day ADL disability was higher for upper (HR = 2.08; 95% CI = 1.21–3.56) and middle groups (HR = 2.10; 95% CI = 1.35–3.27) in the US but only the upper group in BR (HR = 1.70; 95% CI = 1.02–2.85).ConclusionA higher PRO‐AGE score was associated with mortality and functional decline in older ED patients admitted to hospitals in the US and BR, demonstrating its generalizability as a geriatric vulnerability risk score.