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Creating a Geriatric
Emergency Department
Creating a Geriatric
Emergency Department
A Practical Guide
John G. Schumacher
University of Maryland, Baltimore County
Don Melady
University of Toronto
University Printing House, Cambridge CB2 8BS, United Kingdom
One Liberty Plaza, 20th Floor, New York, NY 10006, USA
477 Williamstown Road, Port Melbourne, VIC 3207, Australia
314–321, 3rd Floor, Plot 3, Splendor Forum, Jasola District Centre,
New Delhi – 110025, India
103 Penang Road, #05–06/07, Visioncrest Commercial, Singapore 238467
Cambridge University Press is part of the University of Cambridge.

It furthers the University’s mission by disseminating knowledge in the pursuit of
education, learning, and research at the highest international levels of excellence.
www.cambridge.org
Information on this title: www.cambridge.org/9781009017701
DOI: 10.1017/9781009039253
© John G. Schumacher and Don Melady 2022
This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.
First published 2022
Printed in Great Britain by Ashford Colour Press Ltd.
A catalogue record for this publication is available from the British Library.
Library of Congress Cataloging-in-Publication Data
Names: Schumacher, John (Gerontology), author. | Melady, Don, author.
Title: Creating a geriatric emergency department / John Schumacher, Associate Professor and Co-Director,
Doctoral Program in Gerontology, University of Maryland, Baltimore County, MD, Don Melady, Associate
Professor, Department of Family and Community Medicine of the Faculty of Medicine, University of
Toronto, Ontario, Canada.
Description: Cambridge, United Kingdom ; New York, NY : Cambridge University Press, [2022] | Includes index.
Identifiers: LCCN 2021024564 (print) | LCCN 2021024565 (ebook) | ISBN 9781009017701 (paperback) |
ISBN 9781009039253 (ebook)
Subjects: LCSH: Geriatrics. | Emergency medicine.
Classification: LCC RC952.5 .S38 2022 (print) | LCC RC952.5 (ebook) | DDC 618.97/025–dc23
LC record available at https://lccn.loc.gov/2021024564
LC ebook record available at https://lccn.loc.gov/2021024565
ISBN 978-1-009-01770-1 Paperback
Cambridge University Press has no responsibility for the persistence or accuracy of
URLs for external or third-party internet websites referred to in this publication
and does not guarantee that any content on such websites is, or will remain,
accurate or appropriate.
Every effort has been made in preparing this book to provide accurate and up-to-date information that is in
accord with accepted standards and practice at the time of publication. Although case histories are drawn
from actual cases, every effort has been made to disguise the identities of the individuals involved.
Nevertheless, the authors, editors, and publishers can make no warranties that the information contained
herein is totally free from error, not least because clinical standards are constantly changing through
research and regulation. The authors, editors, and publishers therefore disclaim all liability for direct or
consequential damages resulting from the use of material contained in this book. Readers are strongly
advised to pay careful attention to information provided by the manufacturer of any drugs or equipment
that they plan to use.
This book is dedicated to my many friends over 90 from whom I have learned so
much – Mom and Dad, Rod, Helen, Glen, Betty, Rosabel, Jim, Bob. And to my much
younger husband, Rowley!
Don Melady
This book is dedicated to my wife and partner, Sarah, who made space for this work to
happen. Also, to my intergenerational teachers, mom, dad and grandmother Nana,
teaching gentle lessons in grace and patient advocacy.
John G. Schumacher
Contents
Acknowledgments viii
Introduction 1 7 Place: Addressing the Physical

Environment 88
1 Making the Case for a Geriatric
Emergency Department 4 8 Quality Improvement in the Geriatric
Emergency Department: Getting
2 Starting a Geriatric Emergency
Started 100
Department 17
Don Melady, John G. Schumacher, and
3 Overcoming Resistance: What to Do Adriane Lesser
with “Yeah, But. . .” 32
9 Launching Your Geriatric Emergency
4 You: An Approach to Your Older Department: From First Steps to
Emergency Department Patients 40 Accreditation 111
5 People: Adding Staffing and
Training 48
6 Processes: Implementing Protocols Appendix: Practical Resources and
and Policies 63 Links 117
Index 137
vii
Acknowledgments
We would like to thank all of our colleagues from several disciplines and many countries
around the world. Their valuable and generous contributions added a lot to this book. They
are all actively involved in improving the care of older people in the world’s EDs. We
couldn’t have produced this guide without their help.
Nemat Alsaba, MD, Gold Coast University Hospital, Australia
Nana Asomaning, RN, MScN, Toronto, Canada
Jay Banerjee, MD, University of Leicester, UK
Fernanda Bellolio, MD, Mayo Clinic, USA
Mary Bennie, RN, MSc, Belmont Hospital, Newcastle, Australia
Kevin Biese, MD, University of North Carolina, USA
Nick Bott, PsyD, Department of Medicine, Stanford University School of Medicine, USA
Audrey-Anne Brousseau, MD, Université de Sherbrooke, Canada
Chris Carpenter, MD, Washington University, USA
Simon Conroy, MD, University of Leicester, UK
Elizabeth Goldberg, MD, Brown University, USA
Paul Ho, MD, Queen Elizabeth Hospital, Hong Kong
Tess Hogan, MD, University of Chicago, USA
Carolyn Hullick, MD, University of Newcastle, Australia
Ranjeev Kumar, MD, Khoo Teck Puat Hospital, Singapore
Osama Loubani, MD, Dalhousie University, Canada
Aaron Malsch, RN, Wisconsin, USA
Pam Martin, RN, Yale University, USA
Stephen Meldon, MD, Cleveland Clinic, USA
Michelle Moccia, RN, DNP, Livonia, Michigan, USA
Simon Mooijaart, MD, University of Leiden, The Netherlands
Colin Ong, MD, Ng Teng Fong General Hospital, Singapore
Ann Osborne, RN, Gold Coast University Hospital, Australia
Adam Perry, MD, Pennsylvania, USA
Thom Ringer, MD, University of Toronto, Canada
Tony Rosen, MD, Cornell University, USA
Carole Sargent, PhD, Georgetown University, USA
Lauren Southerland, MD, Ohio State University, USA
Jiraporn Sri-On, MD, Navamindradhiraj University, Thailand
viii
Acknowledgments ix
We extend a special thank you to Paul Webster for his editorial suggestions and
guidance as the book developed.
Don Melady receives an annual stipend from the Geriatric ED Collaborative. One of his
job requirements in that role is to promote the dissemination and implementation of
Geriatric ED models of care. He also sits, on a voluntary basis, on the Board of Governors
of the Geriatric ED Accreditation Program, which is a not-for-profit offering of the
American College of Emergency Physicians.
John G. Schumacher has no disclosures of potential conflicts of interest.
Introduction
Do you sometimes have the uneasy sense that something in the emergency department
where you work needs to change? Does this feeling stem from the treatment of older
patients? Do you hear comments like, “Is it my imagination, or are there lots more old
people around?” or “there are so many complaints from older patients” or “why is it that
looking after older people in the ED is so hard?”
If any of those comments echo what you’re thinking and hearing in your ED, this book’s
for you. We speak directly to you and other ED clinicians, administrators, and hospital
leaders who want practical guidance about how to improve their ED’s care of older people.
We want to provide you with immediately applicable information and even a road map to
start improving care of your older patients. In this book we offer a guide that’s both
evidence-based and experience-based. We’ve packed it with actionable information to
give you ideas about how to change your ED’s structures, processes, and outcomes. And
we’ve organized it to provide a step-by-step framework for any ED, large or small, to assess
and address its readiness, staffing, processes, equipment, resources, and space as it seeks to
improve the ED care of older people.
This book grows out of the authors’ experience – 60 years between the two of us – of
working in the field of Geriatric Emergency Medicine (EM). Don Melady has been an
emergency physician for 30 years. During his whole career as a clinician and educator, he’s
taken an active interest in how he can improve his own care of older people and how systems
of care can be changed to do the same. Based at Mount Sinai Hospital, University of
Toronto, Canada, he is the founding chair of the Geriatric EM Committee at the
International Federation of Emergency Medicine. John Schumacher has been a bioethicist
and medical sociologist for 30 years, focusing on EDs and researching the care provided to
older people. His career has concentrated on improving the interactions between phys-
icians, older patients, and the settings in which they take place. He has consulted on the
creation and operation of numerous Geriatric EDs as a faculty member based at the
University of Maryland, Baltimore County (UMBC), USA.
Our book has also benefitted from contributions, suggestions, comments, and good advice
from our colleagues around the world, an international list of Geriatric ED authorities –
nurses, doctors, and academics who focus their practice on improving care of the older ED
patient.
It’s no secret that in almost every country of the world, the population of older adults is
rising steeply [1]. Not surprisingly, these demographics link to an increase in the number of
older people in EDs across the world. We know that EDs have treated older patients since
their inception, accumulating extensive experience with this patient population. However,
while we have seen significant practice advances in the area of Geriatric Emergency
1
2 Creating a Geriatric Emergency Department
Medicine over the past 30 years, many of them have not been integrated into mainstream
ED practice. In fact, relatively few EDs have made any of the systematic changes described
here to prepare for the growing number of older ED patients. Empirical research is slowly
emerging. And experience suggests that EDs implementing changes like those in The
Geriatric ED Guidelines [2] or the European Geriatric Emergency Medicine Curriculum
[3] report consistent improvements in outcomes, better functioning, reduced costs, and
higher staff satisfaction.
This book is aimed at helping practicing ED interdisciplinary clinicians, ED leaders, and
hospital administrators who are responsible for providing acute care to older adults.
Colleagues who are involved in quality improvement and continuing education programs
may benefit from much of its focused content and suggestions. Hospitals involved in
graduate medical education for emergency medicine and emergency nursing may find
this book a valuable resource for programming. Finally, hospitals considering accreditation
by the American College of Emergency Physician’s Geriatric ED Accreditation (GEDA)
body (www.acep.org/geda/) may find this book a helpful resource.
We recognize that EDs are highly varied, both nationally and internationally. We have
organized the nine chapters of this book to transcend the structure of any single ED or
medical system with an eye to providing guidance that can be tailored to any ED. We want to
provide a brief evidence- and experience-informed practical guide to get you started on
improving your ED’s care of older people.
We start with the first chapter titled “Making the Case for a Geriatric Emergency
Department.” First of all, we clarify that a Geriatric ED refers to any general ED that is
making changes to improve the care it provides its older patients. We give you some
rationale for making this change to convince your hospital’s leadership and provide you
with some evidence and scripts to use when pitching the idea. Chapter 2, “Starting
a Geriatric Emergency Department,” gets into the nuts and bolts of the first steps of
assessing your current ED, identifying your allies, and exploring different models of
Geriatric EDs. In Chapter 3, “Overcoming Resistance: What to Do With ‘Yeah, But . . .”
we share practical strategies for addressing the push-back you may get from pioneering
a Geriatric ED.
Chapters 4, 5, 6, and 7 are the core of the book’s “practical guide,” with lots of
information and suggestions about how things can be different in a Geriatric ED.
Chapter 4, “You: An Approach to Your Older Emergency Department Patients,” describes
some key changes that clinicians may want to adopt or adapt in their approach to older
people.
Chapters 5, 6, and 7 introduce the Geriatric ED’s 3 Ps of people, processes, and place.
Chapter 5, “People: Adding Staffing and Training,” examines the staff roles necessary to
implement a Geriatric ED including the central Geriatric ED nurse care coordinator role.
Then Chapter 6, “Processes: Implementing Protocols and Policies,” presents the wide range
of process changes that could be made as part of a Geriatric ED. The focus of Chapter 7,
“Place: Addressing the Physical Environment,” is the small additions and changes you can
make to geriatricize your ED, as well as the large reconfigurations of the physical space.
Chapter 8, entitled “Quality Improvement in the Geriatric Emergency Department:
Getting Started,” provides an introduction to integrating quality improvement efforts into
the Geriatric ED. Our conclusion, Chapter 9, “Launching Your Geriatric Emergency
Department: From First Steps to Accreditation,” encourages you to take action and begin
your efforts to improving care for older adults in the ED. The Appendix includes references
Introduction 3
to commonly used assessment tools, model policies, and a list of adaptations to the physical
environment used by Geriatric EDs around the world.
Throughout the book, we’ve provided personal accounts from many different EDs
internationally to put a human face on Geriatric ED change. They are stories from people
working in big cities, small towns, and academic and community hospitals around the globe
about how and why they got started on this journey and about the outcomes they have seen.
Overall, this book is designed as a practical guide for interested ED people who want tips,
tricks, ideas, and suggestions based on evidence and experience for better ways to organize
their EDs to measurably improve care of the rapidly growing population of older ED
patients.
Our ardent hope is that the insights we offer will make your life as a clinician better, and
that, as a consequence, your older patients will get even better care than they already do.
Nurses Association, and Society for

References Academic Emergency Medicine. Ann Emerg
1. United Nations Population Division. World Med. 2014;63(5):1–3.
population prospects: The 2017 revision –
key findings and advance tables. Working 3. Bellou A, Nickel C, Martín-Sánchez FJ,
Paper No. ESA/P/WP/248; 2017. et al. The European Curriculum of
Geriatric Emergency Medicine:
2. Carpenter CR, Bromley M, Caterino J, et al. a collaboration between the European
Optimal older adult emergency care: Society for Emergency Medicine
introducing multidisciplinary geriatric (EuSEM) and the European Union
emergency department guidelines from the of Geriatric Medicine Society
American College of Emergency Physicians, (EUGMS). Emergencias. 2016;28(5):295–7.
American Geriatrics Society, Emergency
Chapter
Making the Case for a Geriatric
1 Emergency Department
“Ms. Hospital CEO, I’ve Got a Proposal and It’s Going to Solve
Some of Your Problems!”
It started as a somewhat zany idea. “A Geriatric ED? You’ve got to be kidding?”
Then it suddenly became a trend. “Really? There are 250 Geriatric EDs in the USA
alone?”
Now, it’s shaping up to be as standard a part of ED practice as the “Golden Hour” and
the “door-to-balloon.”
Yes, hundreds of hospitals around the world have created Geriatric EDs in the past
decade to better serve older people. Each one is unique and was created for unique reasons.
But each hospital’s decision to create a Geriatric ED was, in all likelihood, simply a sensible
and often overdue response to the growing needs of its older ED patients, families, staff, and
hospital.
Now, when we say, “Geriatric ED,” we don’t mean what you probably think we
mean: It is NOT a separate space, down the hall, custom-built, exclusively for older
patients – although a few are. Rather, when we use the term “Geriatric ED,” every-
where in this book, it means a regular general ED that has made the decision to
intentionally implement changes in its people, processes, and place in order to
improve the quality of care it provides to older patients – regardless of physical
space or resources.
We believe that every ED has the capacity to adopt a different culture of care in order to
become a Geriatric ED. You don’t need millions of dollars of rebuild and half a dozen new
employees to make it happen in your ED. The changes we’re guiding you to are available to
every ED, large, small, urban, rural, community, or academic.
In thousands of hospitals worldwide, the same scenario is unfolding with increas-
ing intensity: Older patients and their caregivers show up to the ED in greater
numbers every day, on every shift, with complex, multifaceted needs demanding
attention. Business as usual is not an option for EDs in responding to these patients.
By joining the Geriatric ED movement, many hospitals transform their care for older
adults and satisfy their financial and funding needs while increasing their staff
satisfaction.
Why Create a Geriatric ED?

The decision to commit to a Geriatric ED model of care is a significant one. It requires
a clear and convincing answer to the basic question: Why do it?
Here’s the answer: demographics and finances.
4
Making the Case for a Geriatric Emergency Department 5
In a nutshell: People around the world – especially in wealthy nations like Australia,
Canada, Europe, Japan, Singapore, the UK, and the USA – are living longer with complica-
tions of chronic diseases, and with a concomitant increase in rates of dementia, along with
often-fraying social support networks. Meanwhile, just about everywhere in the world
growing numbers of older adults are visiting EDs with ever-increasing frequency. Once
they’re at an ED, there’s strong evidence that they use more resources per visit, are more
likely to get expensive tests with advanced imaging, are more likely to be admitted, and are
more likely to suffer healthcare-related harms. Adopting a new approach to their care – with
sometimes small changes in structure and processes – can have a big impact in terms of
improved outcomes for patients while saving money for your hospital [1–3]. As the
demographic Silver Boom continues over the next two decades, the changes presented in
this book are essential both on moral grounds and if you want to achieve financial
sustainability and ongoing quality of care in your ED.
For a more detailed answer, read on.
To date, hospital EDs around the world have responded to the question, “Why?” by
reimagining all or parts of their EDs in a form that is broadly described as a Geriatric ED
[4,5]. Not surprisingly, these early adopters vary widely in their Geriatric ED staffing,
policies and physical environments. But when we take a quick look across them, three
common reasons stand out (Table 1.1).
Table 1.1 Common reasons: Why create a Geriatric ED?
1. The compelling business case

2. Increasing number of ED visits by older patients
3. The “ground truth” of improving care for older ED patients
Box 1.1 Sample Elevator Pitch for Your CEO
You: Hello Natalia! It’s time our ED caught up with a lot of other hospitals to start a Geriatric
ED. We’re getting left behind.
Honestly, if you ask most of the ED staff, they’ll tell you that we don’t do a very good job
with older people. They stay too long in the ED; they’re the ones who always end up bouncing
back; we’re admitting way more of them than we need to; they’re clogging up the ED and
hospital needlessly both for them and for us.
We could be doing better and I don’t think it needs to cost a lot of money. We already have
some of the people we need. One of our docs would love to take this on as a project. We
already have a social worker and a physiotherapist. But they could be better used if we
focused them on the older patients. However, we do need a specific geriatric nurse care
coordinator to pull the team together. That’s going to cost money – probably $120,000 a year.
Nevertheless, results elsewhere suggest that by putting that team together, you can make
a huge difference in outcomes. I’m sure we can avoid at least one admission per day. That
would way more than balance the expense. Other places that have done this kind of thing are
saving up to $3 000 per patient. And we see a lot of these patients! Plus, it could make a huge
difference on ED flow and on increasing inpatient capacity and your bottom line. It’s also the
kind of thing that gets a lot of positive attention in the press. Patients and families love it. Can
I put together a proposal for you?
The Compelling Business Case

We’ll get to the demographics and “truth on the ground” arguments shortly. But surely the
most compelling argument to the question, “why do it?” resides in the business case. This
needs to be articulated clearly for your hospital leadership to accept that change is needed.
Your job is to remind them or convince them that not only does a Geriatric ED provide
better-quality care to a large part of your patient base, it can also save the hospital money
and put it on a surer financial footing.
To make this case, you need to think about what keeps a hospital executive awake at
night. Those things include “how do we ensure we’re providing the best care possible?” They
also include “how do we ensure the hospital is financially viable and that we have the money
we need to provide the best care possible?” Be ready to frame your proposal in those terms.
Here’s one example:
Dr. Goodperson saw the value of creating a Geriatric ED at Good Intentions Memorial Hospital.
But she knew that upfront capital and some operational spending, even if just a small amount,
would be a hard sell to the cash-strapped board. She started by speaking with her ED chief to
better understand how the department was funded, and what challenges it faced. She learned
that the Ministry of Wellness, its principal funder, penalized departments that had long lengths
of stay (LOS) and excessive admissions. Their department’s LOS had been increasing over the
last decade. And much of that increase was for older people who ended up being admitted for
“social issues.” Many of those issues were things like mobility, functional decline, caregiver
burnout, safety issues at home, which were not easily addressed by inpatient treatment and led
to prolonged admissions with associated bed block.
Her chief was willing to share the funding and penalty formula. Based on that,
Dr. Goodperson started with a simple “What if?” What if we could reduce the LOS for such
patients by just one hour? What if admission could be avoided for just 1 out of every 20 patients
who would otherwise be admitted? She gathered data about the number of admissions and did
a quick back-of-the-envelope calculation, discovering that by reducing LOS by one hour on
average and avoiding 5% of social admissions, the department could avoid $250,000 each year
in LOS penalties from its funder! For a project that might cost just $100,000, that was a big return
on investment that any CEO could appreciate!
The following argument is highly persuasive to your executive leaders. Unscheduled

acute admissions to hospital, like Dr. Goodperson’s so-called social admissions, are rarely
“financially desirable” admissions for your hospital [6,7]. This applies particularly to older
patients who consume large amounts of resources, especially nursing, even though they
have relatively “low-paying” admissions diagnoses. They sometimes end up with
a prolonged length of stay through poorly managed painful conditions, lack of attention
to frailty, and incident delirium. Hospitals would usually prefer to find more appropriate
alternatives to providing the care those patients need, while ensuring that patients receive
excellent care. The high-paying desirable admissions are the high-intensity surgery and
complex medical interventions (cancer and transplant surgery, cardiac catheterizations,
interventional radiology, etc.). But hospitals cannot welcome those patients if all the beds
are full of older people, just waiting for their physical therapy assessment (that could have
been done in the ED) while simultaneously encountering all the hazards of hospitalization –
confusion, deconditioning, poor nutrition, and sleep deprivation!
These are the grim realities of hospital funding that we rarely consider in the ED. But
your executives know them well, and that’s what keeps them up at night. Fortunately, you
can tell them that you can solve a lot of those problems by improving the use of scarce
inpatient beds. With a small investment and executive support, you are proposing an
efficient, relatively low-cost interdisciplinary ED team, and a department armed with
older person-focused protocols and policies. Your move toward a Geriatric ED will ensure
that older people are thoroughly assessed, linked with appropriate resources, flawlessly
transitioned to appropriate care, and, if admission is necessary, are more completely
assessed so that a targeted time-limited admission is possible. This is the classic win-win
of game theory: older people coming to your ED get enhanced quality care; staff in the ED
are able to perform more effectively; and the hospital addresses some of its biggest funding
challenges.
Healthcare systems around the world are moving away from a fee-for-service model
(“you do something; we pay you”) to a value-based model (“you do something well; we pay
you more”) and progressively to a risk-based model (“you do something badly; we take
money away from you”). In this new world, payor systems, private or government-
managed, emphasize value: maximum quality for reduced cost. Fortunately, you can
demonstrate that your proposed Geriatric ED transformation will deliver that equation.
By enhancing the structures and processes of your ED, what we could call Geriatric ED
interventions, to better assess and manage older patients, there is ever more emphasis on
providing increased value. A team approach and standardized protocols give the patient
what they need. They get not just a splint for a broken wrist and a pat on the back as they
leave. They also get an assessment of their fall that considers their medication list; provides
PT assessment for strength conditioning to prevent the next fall; and coordinates links to
necessary social services. This approach ensures that they do well at home and the hospital is
not financially penalized for an avoidable ED revisit. The hospital is also not penalized for an
unnecessary admission of this frail older person who is admitted “for further assessment”
just because they are not “safe for discharge” and the emergency doctor has no alternatives
available.
Fortunately, based on a large study published in JAMA Open, you can now tell your
hospital executive that there is strong evidence that Geriatric ED interventions are associ-
ated with cost savings to Medicare of up to $3 000 per patient [1,8]. Going back to
Dr. Goodperson’s back-of-the-envelope, if 20% of your 60 000 visits per year are people
over 65, and your healthcare system saves $3 000 per patient, that could be a very large
number of cost savings! Clearly, not all of that saving accrues to your ED but as systems
move toward value-based methods of payment, improvements in outcomes will likely
translate soon to incentive payments to your institution.
Your argument will also need to reinforce that providing high-quality care to your
largest single-user group, older people, is consistent with your hospital’s mission, values,
and financial goals. Probably its mission statement includes something along the lines of
“delivering excellent care, with optimal outcomes, while addressing patients’ values, and
doing so in a cost-effective manner.”
But can you tell your CEO about the lady you saw last week? She is the one who waited
four hours to have her ankle fracture diagnosed and then went home without anyone
considering why she had fallen (because no one had been prompted to investigate). Her
dementia (that no one had identified) had caused her to triple up on her anti-hypertensives
(that no one had assessed) leaving her persistently presyncopal. Once discharged home,
with no community follow-up (that no one had arranged), she couldn’t manage without
a gait aid (that no one had offered), and continued taking her meds in the same way.
Predictably, she had another fall two days later, this time with a broken hip. On her return to
your ED, her delirium was not identified in the ED (because no one screened for a change in
mental status). As a result of the delirium, she has had a markedly prolonged hospital stay,
for which the hospital is still paying. Oh, and did you mention that she is the mother of the
town’s mayor?
In what way does this story fit with the hospital’s mission of excellent care, optimal
outcomes, respect for patient values, and cost-effectiveness? Unfortunately, you know that if
you audit just one month of older patients in most EDs, it’s quite probable you’ll find more
than one story that fails on some of those fronts. How expensive – measured in financial,
reputational, and moral costs – is each of those stories? How much would your CEO invest
to prevent even one? One a month? One every day? Make sure you know your hospital’s
strategic priorities and refer to them often. They’re important!
Targeting improved care for your principal user groups can also have a strong impact on
“market share.” Hospitals are not a business like all others. But they do need to have
“customers” coming through the door if they are going to be seen as valuable and contribu-
tory parts of their communities and to remain financially viable. When older people are
attracted to your ED and not to the “other” hospital, they also bring the rest of the family. So,
because Mom gets excellent ED care for her fall and head injury, it is more likely that Dad
will be coming to you for his hip replacement and daughter for her obstetrical care and son
for his complex cancer surgery. While providing good care to Mom is not a high-revenue
activity, the other three are. As an example, there is some emerging evidence that hospitals
with Geriatric EDs showed less of a drop-off in usage, visits, and therefore revenue during
the COVID pandemic than those without.
To some extent, these changes require a visionary eye. But most executives hope to be
visionaries. They either want to lead or at least not to be left behind! It should not be difficult
to convince an executive that providing better care to a larger number of older patients by
making some intuitive changes at the front door will pay quality dividends to the patient and
financial dividends to the institution.
Now Let’s Crunch Some Other Numbers!

Your executive leader will want more than just aspirations in order to support change.
Quantifying the business case begins with an analysis of current demographics and pro-
cesses. Assemble the data that are specific to your site. They should include:
• number of people of age ≥65 in your catchment area including, gender, race/ethnicity,
socioeconomic status
• number of people of age >85 (typically the higher-intensity ED users)
• number of people of age 55–64 group since it includes the group of people aging into the
age >65 by 2030 – the Baby Boom turning into the Silver Boom
Look for patterns within those populations:
1. The proportion of people of age >65 within your ED population (this is a telling number
that ED staff often overestimate – it’s usually much lower than they think. Learning that
it will likely double over the next 10 years can be a great spur to action!)
2. Current ED process measures such as:
• ED length of stay for patients >65, >75, and >85
• ED to hospital admission rate for patients >65, >75, and >85
• ED readmission rates for patients >65, >75, and >85

• ED revisits at 3 days and 28 days for patients >65, >75, and >85
• Patient satisfaction scores
Learn about how your ED gets its revenue: How is it paid? How is it penalized? What are its
main “moneymakers”? What are its financial problems? What are the realities around staff
remuneration? You’re proposing changes to both structure (IT, education and training, staff
hires, infrastructure) and process (new protocols, new workflows). What are the related
costs? Can you imagine increased revenue associated with any of your changes? What about
savings?
You’ll be assisted in these calculations by an online Geriatric ED Return-on-Investment
Calculator that allows you to plug in many variables and come up with some numbers-based
arguments to present to your leadership: https://surfcovid19.shinyapps.io/ged_calc/.
You: Hello Freeman! Good to see you.

Freeman, I’d like to share what I’m working on at the moment – it’s creating a Geriatric ED in
our ED. We are designing it to both improve care and help the hospital. You see, in the past
five years, our 65+ patient volume has increased 30% and now is the largest single cohort we
see. Older patients are 30% of our ED bounce-backs and that’s knocking a big hole in revenue
and staff morale. Our processes are not a good fit, which is slowing us down. Often, our older
patients end up admitted just because everyone gets frustrated that there’s no good options.
To address the situation, I want to modify the job description of some of our staff, probably
add a new person, change a lot of processes, and add some basics to the place, including
some IT changes. I’ve got an ED physician champion and we plan to hire two overlapping
geriatric emergency nurse care coordinators. They’ll do a lot of the needed service coordin-
ation and train the rest of our staff. It’s all going to take some money – probably $200,000
a year. There’s a definite return on that investment – decreased avoidable admissions and
shorter length of stay. I know patients will love it and boost our patient satisfaction scores.
Probably fewer complaints. Definitely fewer return ED visits. It could easily save us more than
$200,000 a year and put us way ahead of the market in this city by creating our Geriatric ED.
What I’d like from you are your support and someone from your executive team to work
with us as a champion.
What else can I put into a proposal for you?
Geriatric EDs Have an Impact on Core Financial Metrics

Complementing these core demographic and financial considerations you’ve now gathered,
you’ll also need to address other metrics for the business case. If you can keep initial costs
revenue-neutral, it will be easier to pitch the expected value from the following:
1. Geriatric EDs Reduce ED Readmissions. Implementing a Geriatric ED model of care is
associated with reducing the number of readmissions of older adult ED patients.
Reducing readmissions is an enormous positive for older patients and their families.
Getting it right the first time decreases the illness experience, lowers pain, anxiety, and
time, and increases patient confidence in your hospital system. It also benefits the ED
since value-based reimbursement policies increasingly include financial penalties to EDs
for readmissions [9,10].
2. Geriatric EDs Increase Levels of ED Patient Satisfaction. Giving patients and families
a sense of thoroughness, completeness, and patient-centeredness definitely improves
patient satisfaction. This improvement may be difficult to quantify financially although
some systems incentivize improving satisfaction scores by remuneration to staff or
funding to a site [11].
3. Geriatric EDs Increase ED Brand Recognition and Differentiation. Although they
are a growing trend, in most locations, Geriatric EDs are relatively rare. Being the “first
on your block” to have one can act as a brand differentiator for both the ED and the
hospital. You may be the only hospital around with an ED that prioritizes geriatric
care, perhaps even an accredited one, thereby increasing your overall health system’s
visibility and reputation. Your Geriatric ED can attract patients from outside your
catchment area who intentionally seek care in your ED thereby increasing the flow of
patients into your health system’s patient population. Enhanced reputation also
increases your ED’s social capital, which allows you to accrue other less tangible
benefits.
4. Geriatric EDs Increase Employee Morale and Retention. Every manager knows that
recruitment costs and poor staff retention are a major drag on financial well-being. The
introduction of a Geriatric ED typically increases ED employee morale. It introduces
a systematic approach to care that fits better with the needs of older patients, and staff
feel empowered to provide higher-quality care to their older patients. Clinicians like to
work in a setting where they feel they are doing the right thing by their patients; where
the number of crisis cases with older patients is reduced because of having access to
a team approach and enhanced processes of care. Employee morale rises with a feeling of
increased competence at treating older patients and of decreased work-related stress,
even of moral distress. Higher employee morale is associated with lower levels of
employee turnover [12].
Table 1.2 lists a summary of questions that may inform some issues related to making
a business case for Geriatric EDs.
Table 1.2 Questions for Geriatric ED business case discussion
1. How might a Geriatric ED impact our ED readmission rate?

2. How might a Geriatric ED impact our ED patient satisfaction scores?
3. How might a Geriatric ED differentiate us from competing hospital EDs?
4. How might a Geriatric ED increase ED staff morale and retention?
Box 1.3 Mount Sinai Hospital Toronto
Joseph Mapa, then CEO of Mount Sinai Hospital in Toronto, Canada, once said, “The ED is not
just the front door to the hospital, it’s also the hospital’s door into the community.” The
hospital was aware that their community was changing and in 2010 the Board of Directors
made excellence in the care of older people one of its strategic priorities. The CEO felt that
geriatric improvements in the ED were “not going to be an expensive challenge. It is not like
creating a new neurosurgical operation room. It’s about creating talent, systems, programs.
With some support, it’s possible to make it happen.” Dr. Howard Ovens, the ED chief, always
identified older patients as “our core users” and made their care a priority. Over his 20 years,
many small gradual changes were added, most of them led by the geriatric emergency
management (GEM) nurses who were the frontline champions of change. One GEM, Nana
Asomaning, remembers the slow implementation of small improvements – acquiring a supply
of walkers and nonslip socks, writing order sets for common presentations, adding geriatric
modules to the nursing education. But her main accomplishment was solidifying the inter-
disciplinary team approach – nursing, doctors, PT, OT, social work all working together on
complex care: “Collaborative work with the team is actually the thing that will get you to the
finish line.”
Figure 1.1 Nana Asomaning, Mount Sinai Hospital, Toronto
The “Ground Truth” of Improving Care for Older ED Patients

Hospitals are not battlefields, but military jargon sometimes produces helpful peace-time
insights. With roots in tactical decision-making, “ground truth” is a term for the influential
descriptions by individuals who directly observe and experience a situation. In the ED, the
frontline nurses, technicians, and physicians are the staff who report the ground truth needed
to improve the care of older ED patients. These honest narratives provide the motivation for
EDs to explore how to address the needs of both patients and staff to create a Geriatric ED.
The ED leadership can help access that ground truth by directly asking staff about their “pain
points” in caring for older ED patients. Where in the process of treating older patients do things
break down in both patient care and flow? Triage? Diagnostic testing? Disposition? Admission
versus discharge to community? Or some other point? Table 1.3 lists some sample questions for
ED staff.
Table 1.3 Questions for ED staff on challenges with older ED patients
1. What are some of your biggest challenges treating older adults in your ED?
2. What are some of your daily struggles in caring for older adults in your ED?
3. What things might make it easier to do your job with your older ED patients?
Providing an opportunity for ED staff to share their pain points when caring for older
patients is a powerful way to gain specific, local knowledge as a basis for change and to foster
buy-in.
The collected ground truth of an ED can be used to inform quality improvement
initiatives. For example, ED staff may identify difficulties assessing older patients
with cognitive impairment as a challenge. A quality improvement effort might start
by asking, “How might we improve our assessment of older ED patients with
cognitive impairment?” This can lead to a set of possible solutions that could be
tested as part of a quality improvement project. For example, if asked, the nursing
staff may bring up how difficult it is to know whether an older person is cognitively
impaired or not – and whether that impairment is new or long-standing. Putting this
problem in the foreground makes it easier to initiate a process – whether it be
delirium screening at triage or later, or the introduction of dementia screening, or
a process for contacting caregivers of patients – that would address both staff needs
and improve patient care.
The Increasing Number of ED Visits by Older Patients

To serve the needs of a population, it’s important to know that population’s vital
statistics. An awareness of basic demographic trends provides important contextual
insights for hospitals considering the creation of a Geriatric ED. The US census reports
that there were about 49 million older adults in 2016. By 2030, in just 10 years, the
number of US older adults will rise to 72 million representing a 50% increase in the
population. On a percentage basis, the US population will move from 13% older adult in
2010 to over 20% older adult by 2030 [13]. Although all areas of the country will see
increasing numbers of older adults, these demographic trends obviously vary. Some
states, like Vermont, Maine, New Mexico, and Nevada, are aging much more rapidly
than others [14].
Internationally, the demographic shifts of aging populations are accelerating in many
countries, led by Japan, Germany, and Italy where older adults already exceed 20% of their
total populations. The United Nations has designated such nations (age 65+ >20%) as
“super aging societies” [15]. As can be seen in Table 1.4, the issue of population aging is
robust in 2019, and by 2030 it shows these same countries as overwhelmingly “super aging.”
These overall demographic trends provide a context for the increasing number of older
adults projected to present to EDs worldwide [16].
Increased Number of Older ED Patients

As populations age, EDs treat an increasing number of older patients. On a national level in
the USA, the number of older adult ED visits increased from 19.4 million to 23.1 million
Table 1.4 Percent of population aged ≥65 (2019) and projected age aged ≥65 (2030)
Country Percent of Population Percent of Population

Aged ≥65 (2019) Aged ≥65 (2030)
Japan 28 31
Italy 23 28
Germany 22 26
Netherlands 20 25
Spain 20 25
Belgium 19 23
United Kingdom 19 22
Canada 18 23
Hong Kong 17 26
United States 16 20
Australia 16 19
Source: World Bank, https://data.worldbank.org/indicator/SP.POP.65UP.TO.ZS?locations=AU/.
World Bank estimates based on age/sex distributions of United Nations Population Division’s World Population
Prospects: 2019 and 2021 Revision. Health Nutrition and Population Statistics: Population estimates and
projections.
between 2010 and 2016. This change represents a 20% increase that mirrors the increase in
the US population of older adults during this period [17,18]. As noted above, the older adult
US population is projected to increase by 50% in the next 10 years. This suggests that EDs
could experience a similar 50% increase in the number of older patients to a total of
35 million visits age 65+ [19].
Increasing Proportion of Older Patients

Based on these projected increases in the number of older ED patients, EDs are expected
to experience a corresponding change in the proportion of their patient population age
65 and older. Currently, older adults make up 15.9% of ED visits nationally [17].
However, as the demography of the USA changes with more older people and fewer
people under the age of 18, the proportion of older ED patients is expected to increase.
Moore et al. [20] report that the proportion of ED patients age 65+ increased between
2006 and 2014 and increases were also seen in the percentage of 45–64-year-old ED
patients. At the same time, ED visits for those aged 0–44 decreased. These shifting ED
patient proportions toward older adults have implications for the types of ED services
offered and staff needed in the ED.
These ED demographic shifts promote EDs to respond in highly sensitive ways.
Table 1.5 lists sample questions for ED staff as the ED leadership plans for the coming
increases in number and proportion of older ED patients. The hospital leadership may
also want to consider these same questions from a workflow and workforce perspective.
Table 1.5 Questions for ED staff about projected increases in older ED patients
1. As a staff member, if your ED experienced a rapid, 20% increase in visits by older adults, what
specific changes might your ED need to make?
2. As a staff member, if older adults become the largest overall percentage of your ED’s patient
population, what are the implications for your ED operations?
3. As a staff member, thinking about your ED over the past five years, how would you describe your
impression of the patterns of older adult ED visits (e.g., increase/decrease of number of visits,
length of visits, chief complaints, disposition)?
Tectonic Drift or Seismic Shift?

Typically, the move toward a Geriatric ED happens in one of two ways. To borrow language
from geology, the change can either be a tectonic drift or a seismic shift.
The tectonic drift toward a Geriatric ED is the slow incremental addition of changes over
a period of time. Maybe for years, your ED has had a physical therapist on staff who
gradually has built in an approach to assessing all patients with falls and coordinating
outpatient plans. And maybe, years ago, you required modules on geriatric topics in your
yearly nursing education. Then a few years back, there was that quality improvement project
to build a delirium screen when you got the new electronic record. And, “Well, we’ve always
had food and drink available and we usually have walkers and canes around to give or sell to
patients at discharge.” Little by little, by slow increments, you are changing both structure
and processes of care. Now, when you look at your people, processes, and place, it’s starting
to resemble a Geriatric ED quite closely!
You: Hello Altaf!

We need to do something with the way we’re doing things down in the ED for older people.
As you know, this small town has become a major retirement destination: Our ED census is
now 40% over age 65. But we don’t have even the basics to manage this diverse group. We’re
still stuck 20 years ago when it was all kids and factory workers. We’re not serving our
community and I think a lot of people go to the hospital in Happy Hills whose ED is focusing
on caring for older patients. We could do just some basic things in our place to get started. I’d
like to get some extra training for a few of our nurses to be geriatric super users, to know more
about our community linkages. We could build in a basic screening tool to the ED chart to
identify people with frailty. They’re the ones most likely to bounce back. Adding a few basics –
like walkers, food and drink (which we don’t have), a comfort cart – would make a difference in
patient experience (and likely our ratings). And our volunteer department says they could
train some of their folks to help out with our patients with dementia. It’s going to cost a bit,
but would likely get us a lot of attention in the community. Some positive attention in the
local newspaper would be a welcome change!
The seismic shift to a Geriatric ED is now happening in more and more places. Perhaps
the CEO of the hospital gets the word that the hospital board has declared excellent care of
older patients as the newest strategic priority for the hospital. “Folks, we’ve got to make
things happen!” Or perhaps a major donor expresses an interest in making a large bequest to
an innovative project that favors older patients. “What about a named Geriatric ED?” Or,
who knows, maybe there’s a new infectious disease that specifically targets older people, and
your ED realizes it needs to radically rethink how it provides care for them – and fast. In
some places, there is an intense pressure to make a change in the way your ED provides care
to older people – to go from zero to a hundred in a year or two. You need to be ready to
respond to that pressure to make a seismic shift to a Geriatric ED.
Conclusions
This chapter examined the question, “Why create a Geriatric Emergency Department?”
Compelling reasons abound. These changes will likely come to your department sooner or
later. If you’re reading this book, likely you’ve already started thinking about how you can
start making changes.
Business as usual is not an option for EDs given the changes they are experiencing
on a daily basis in their ED patient population. Patient data analysis almost always
shows that EDs are experiencing a rapidly increasing number and proportion of ED
visits by older patients. Beyond the data analysis, frontline ED clinical staff report
ground truths regarding the need to improve ED processes for older ED patients. It’s
clear to ED staff that there is a need to improve their care of older adults in their ED
and that a quality improvement effort in the form of a Geriatric ED may be a way to
gain momentum.
Fortunately, the concept for a Geriatric ED also has a strong business case for the
hospital. Some of the more intangible impacts are an increase in market share, reinforced
brand recognition, enhanced reputation, and additional philanthropic support. But in terms
of direct funding, it is likely to decrease avoidable admissions, decrease early ED revisits and
hospital readmissions, improve patient satisfaction scores, and have an impact on staff
morale and therefore recruitment and retention.
Now that you’ve got your CEO’s attention for why they need a Geriatric ED, Chapter 2
will explore how you can go about building the proposal.
4. Hwang U, Morrison S. The geriatric

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Chapter
Starting a Geriatric Emergency
2 Department
Where Do I Start?
After your brilliant pitch to the CEO (see Chapter 1), they gave you the go-ahead to make
some preliminary plans and prepare a proposal for consideration at next month’s executive
report to the board. Now what? This chapter provides a guide including:
1. You’re not starting from zero
2. Articulating what’s important to your ED and your hospital
3. Mapping truths about your ED and older adults
4. How might we create it: assess ED with 3Ps – people, processes, place
You’re Not Starting from Zero

You’re not the first ED in the world to consider making some changes to the way you
provide care for older ED patients. So, you’ll probably do what most of us do when we
have a new project – phone a friend! While every ED is different, you almost certainly
will benefit from reaching out to other Geriatric EDs, of which there are an ever-
increasing number. In whatever country you work, there are likely a few EDs that are
leading these changes and will be happy to share their experiences of what worked and
what didn’t at their place. An organization like the Geriatric Emergency Department
Collaborative (GEDC), based in the USA, has the mission of dissemination and imple-
mentation of older-person-focused models of ED care (https://gedcollaborative.com).
International [1], European [2], and Australian Emergency Medicine [3] organizations
have all developed guidance for departments wanting to make change in their
Geriatric EDs.
Your new friend will likely tell you that there are a few core documents you should
master before you go much further. Back in 2012, when the field of Geriatric Emergency
Medicine was still developing, a group of American collaborators got together to establish
general, experience- and evidence-informed guidelines about the characteristics of
a Geriatric ED. The resulting document, The Geriatric ED Guidelines, was codeveloped
and adopted by an interdisciplinary group of the American College of Emergency
Physicians (ACEP), the Society of Academic Emergency Medicine, the Emergency Nurses
Association, and the American Geriatrics Society [4]. That document has informed the
creation of most Geriatric EDs today, whether they be the relatively rare approach of a free-
standing separate ED or the more common model of a general ED that has been “geria-
tricized.” It remains essential reading for any ED that is starting down this road. Many of the
suggestions in this practical guide are based on it.
17
As Geriatric EDs started to proliferate, in 2018 ACEP created a program to accredit EDs,
at three different levels, that have transformed their care sufficiently to be called a Geriatric
ED (see Chapter 9 for more detail). Even if accreditation is not a goal for your ED, the ACEP
criteria are also essential reading to help you understand the range of changes that are
available to you as you improve your ED’s approach [5]. They also give guidance about an
approach to quality improvement efforts in your ED and the metrics you need to measure.
Finally, two brief resources will round out your introduction to Geriatric EDs. First is
a guide by West Health, a foundation committed to improving care of older people, that
produced an implementation guide to help you get started: www.westhealth.org/wp-content
/uploads/2018/09/GED-Implementation-Guide.pdf. The second is a robust tool kit called
the Geriatric Emergency Department Intervention (GEDI) Toolkit created by the Health
Care Improvement Unit in Queensland, Australia: https://clinicalexcellence.qld.gov.au/res
ources/gedi-toolkit. With these few resources you will have a solid foundation in Geriatric
ED development.
Even within your own department and hospital. There may be opportunities that you
can exploit to get started. One ED manager noticed that she had access to a physical
therapist but the PT was often doing relatively low-impact activities like crutch-teaching
and demonstrating stretching exercises for people with back pain. She re-focused the PT
role specifically on assessing older people with falls to determine functional ability and how
to optimize it for discharge. She was able to provide more value to the patient and produce
a much more satisfied PT, and improve the quality of care with fewer bounce-backs because
of failing function at home [6]. Similarly, it may be possible to refocus your pharmacy
services more specifically on older patients – not creating a new role but getting more value
out of what resources you already have [7].
What’s Important to Your ED? What’s Important to Your

Hospital?
Following the recognition that your ED already treats older ED patients, and conducting
some preliminary analysis of your census of older ED patients, we have found the next step
is for the ED staff to write down their answer to two questions: (1) What is important to
your ED? (2) What is important to your hospital?
While these may seem simplistic – “Of course we know what is important!” – we have
found that the ED team need to discuss and write down what they think is important in the
ED since the answers may or may not be consistent across the ED leadership, ED staff, and
the hospital administration. An alternative way to think about this is to ask: What are the
indicators that your ED is doing well? Some EDs have a “dashboard” of indicators that they
monitor. Even the choice of what indicators are on that dashboard can reveal a lot about
what is important. These indicators may include: number of ED patients treated; ED patient
satisfaction; ED revenue; number of ED 48-hour readmissions; and number of 30-day
hospital readmissions. It’s surprising how often these indicators are not segmented by age
and that may be your first task. The key is to know and write down the metrics that are
explicitly used by the ED and hospital to measure success.
At the same time, the hospital may have a specific set of hospital-wide indicators that it
tracks to measure “success” in its own hospital-wide dashboard. Once again, it is important
to document these hospital-level indicators of success, ideally over both a one-year and
a five-year period to establish patterns over time, and your interpretation of them.
Starting a Geriatric Emergency Department 19
Next, compare dashboard items important to the ED to dashboard items that are
important to the hospital. To what degree are the dashboard lists consistent? Is there
a gap between what is important to the ED and what is important to the hospital? For
example, is it important for the ED to avoid hospital admissions/readmissions (avoidable
hospitalizations) compared to the hospital as a whole where hospital admissions may be
something that is important to the financial health of the hospital? It is not uncommon for
there to be conflict in areas of importance that may impact the organization and functioning
of your Geriatric ED.
Next, explicitly consider how older ED patients (age >65) may drive the indicators you
listed as important to the ED and to the hospital. What might be the relationship between
older patients and the indicators you list? Spend some time hypothesizing about these
potential relationships and pathways. What role can you suggest older patients play in your
ED’s and your hospital’s measures of success? As you do this, remember, do not make
“perfect the enemy of the good” as noted by Jim Collins in Good to Great (quoting Voltaire!).
These answers may be a little tricky and a little messy and that is okay. You will gain insight
by comparing these areas of importance as seen from the perspective of the ED and the
hospital.
Truth-Mapping Exercise: What’s True about Older Adults

in Your ED?
With an initial understanding of what’s important to your ED and hospital, you can deepen
your understanding by doing a “truth-mapping exercise.” Truth mapping is a simple and
powerful technique that is inspired by the work of Patrick Lencioni [8]. The exercise
involves a team listing on a whiteboard everything that they know is “true” about their
organization. This could be done with an online survey with all your staff. Or, as you are
assembling a core team, you may want to pull them together for this exercise. Get one or two
nurses, a doctor, perhaps a clerical or service staff person, someone from administration
together. Then ask them to list what they know is “true” about how they care for older adults
in their ED.
The goal is to develop a robust, redundant, chaotic, perhaps messy list of everything they
can think of related to older adults and their ED. Things on the list can be positive, negative,
or neutral. Make the list as long as you can in the time allotted. Lencioni notes your list may
include “apples, oranges, monkey, and Cadillacs.”
One ED’s list might look like this:
• We don’t differentiate older from younger ED patients
• Our exam rooms are uncomfortably crowded when an older patient has more than one
family member
• One nurse, Nancy, is extremely patient with older patients who are confused
• Older patients have really long charts
• Triage is a disaster for old people – they can’t hear, I can’t hear, I’m getting stories from
paramedics/the patient/the family
• We have graham crackers, ice chips, and ginger ale for our patients
• Some staff hate seeing older patients
• Ambulance staff don’t like transporting older patients
• Our local nursing home sends us many old patients with no information
• Disoriented, combative, older patients require a lot of nursing attention

• We do not provide transportation back to older patients’ homes
• Few older people have advance directives
• Some older patients are surprisingly spry and with it
If your colleagues are open and honest, it’s likely that this process will reveal a lot of gaps
between where you are and where you’d like to be. This is sometimes called an “expectancy
gap” – the difference between expectations and experiences. Larger expectancy gaps are
associated with increasing levels of staff dissatisfaction and turnover across many organiza-
tions [9]. Defining and documenting expectancy gaps by ED staff related to the care of older
ED patients can help to motivate the change needed to close them.
Hearing the voices of ED staff members about the care of older people may reveal
frustration and elements of ageism related to such care using the standard ED model of
care. ED staff may express frustration about an older patient’s inability to quickly report
their medical history or give an accurate medication list [10]. ED staff may find it
challenging to reconcile seemingly nonspecific and vague symptoms with a “standard”
emergency medicine algorithmic approach. Staff with little experience of care techniques
for people with cognitive impairment may be frustrated by repeated questions or
requests or unusual “annoying” behaviors. Tracking down all the information from
many different sources – patient, family, care institution, medical record, medication
record, community providers – may be daunting and even overwhelming for a single ED
staff member [10]. These examples of the expectancy gap, once expressed, may provide
valuable arguments for moving ahead with changes – and give some direction as to what
to target first.
Next, you can begin to analyze your list to start looking for categories, patterns, and/or
themes among the “truths” you listed. What things seem to go together? In this process,
insights about older adults in your ED will naturally emerge. This analysis is an imprecise,
meaningful, and fun process. Some things might go in two categories. However, place each
item in one category and begin to see what themes are emerging from your list of truths.
There are no wrong answers here as you are simply mapping things that are currently true
about your ED and your older patients. The emerging categories will serve as anchors to
help you assess and understand where your ED is right now in terms of older patients. With
this organically developed knowledge, your ED is better informed about your current
starting place. Your ED older adult “truth map” identifies fundamental elements of your
current environment. With this baseline knowledge, your ED can begin imagining how you
can redesign your ED to improve your care of older patients.
What Do the Numbers Tell You?

To complete the assessment of your ED’s current care of older patients, we recommend you
conclude with an assessment that quantitatively characterizes your older adult ED patient
population.
Characterizing Your Older ED Patient Population

Characterize your ED patient population by examining patient metrics on your older adult
ED patients by month over the past 12 months with an extension looking at 5-year trends
for the variables. Start with the following set:
ED Census
• How many ED patients were aged 65 and older?
• How many ED patients were in these age categories: 65–74; 75–84; 85–94; 95+?
• What is the breakdown of ED patients aged 65 and older by age, gender, and race?
It may take some work to assemble these data points, but it is essential to have them as you
move ahead with planning and advocacy and preparing your various quality improvement
measures.
ED Processes
Among ED Patients Aged 65 and Older
• What was the average length of stay?
• What was the triage acuity level?
• What were the top five chief complaints?
• What screening tests were completed?
• What were primary discharge diagnoses?
• What was the discharge location?
Based on this collected data, you will begin to develop insights into your ED’s experience
with older patients. Write these down.
What Patterns and Insights Emerge about Your ED’s Care of Older People?
In addition to insights you can gain, it is critically important to organize and review
this patient-level data because at some point you will be asked: “Based on what
information do you make these proposals for the ED?” Having access to these numbers
and analysis will allow you to make a compelling case for your Geriatric ED based on
your own ED data.
At this point, you have a sound foundation. You recognize you are not starting from
zero. You know what is important to your ED and your hospital. You have listed current
“truths” about your ED and older patients. You know the characteristics of the older adult
ED patients visiting your ED over the past 12 months. This review allows you to focus on
your current ED reality and not vague aspirational ideals. It will help you sound like an
expert!
What about Your Structure, Processes, and Outcomes?

To continue your assessment of your ED’s readiness for older adults you can look at
three additional domains. We have broken these down into the categories of structure,
processes, and outcomes, a construct that will come up throughout this book.
1. Your current ED staff and its geriatric competencies (structure)
2. Your ED’s physical space and its suitability for older adults (structure)
3. Your ED policies and their relationship to the care of older ED patients (processes)
4. What happens to older patients after they have been in your ED (outcomes)
Your Current ED Staff and Its Geriatric Competencies

A careful cataloging of your current staff may reveal some hidden treasures. Maybe one of
your ED staff nurses used to work in long-term care. Maybe one of your physicians studied
gerontology as a premed student. Maybe one of the registration staff does volunteer work
with a community aging support agency. Maybe some of your staff are pursuing or already
have training in palliative medicine. Or maybe the chair of the department is caring for two
aging parents with dementia. All of them can be leveraged to become allies and role models,
future members of the interdisciplinary team, or just Geriatric ED super users.
Your ED’s Physical Space and Its Suitability for Older Patients
You can take a good look at the ways in which your ED’s physical space is appropriate for
care of older patients. You may look at signage and wayfinding, seating, lighting, fall
hazards, access to toilets, and easy arrival and departure. But think about all the other
parts of the place that improve the patient’s experience – food, drink, access to gait aids, to
hearing assists, to things that promote both physical and psychological comfort. It’s
probably not perfect – remember “perfect is the enemy of good!” – but you might be
surprised that you have some strong points and some clear areas for improvement.
Your ED Policies and Their Relationship to the Care of Older ED Patients

As part of the tectonic drift model of Geriatric ED development, sometimes over time, EDs
develop policies that relate generally or specifically to care of older patients. There may be
specific policies to guide the use of restraints for patients in general that can be modified for
geriatric considerations, or screening for fall risk, for delirium, for polypharmacy. Or
there may be policies that just need some tweaking – like a policy around screening for
domestic violence that can be expanded to consider other forms of elder abuse, or noticing
that your primary nurses already record a Richmond Agitation and Sedation Score, which
just happens to be 50% of the Delirium Triage Screen (see Chapter 6). See if you have any ED
policies that have been specifically designed for your older ED patient population.
What Happens to Older Patients after They Have Been in Your ED

You should assess some measure of outcome of your older patient’s ED visit. At the most
extreme end, you could determine the short-term mortality rate – how many people die
within a week or a month of their ED stay. We have already mentioned the important metric
of ED return visits at 72 hours and 30 days that you’re probably already tracking. However,
you might also determine how many people are connecting with community services after
discharge; how many are following up with their specialist appointments; how many go to
acute care rehabilitation or to hospice care; how many primary care providers are notified of
their patient’s ED visit. All of these data points will provide guidance for enhancing your care.
We Need a Geriatric ED Because . . .

Based on your background work above, your next step toward creating a Geriatric ED is to
write down your own response to the stem “we need a Geriatric ED because . . .” The
“writing down” is critical. People commonly talk about issues. It is only when they are
documenting it in writing that actionable plans are formed.
You will find this documentation pays dividends when you start implementing real
changes. Being able to go back to your (agreed upon) reasons and goals can be a powerful
tool for change. For example: “But we agreed that decreasing delirium incidence was
important! We can’t do that unless we identify who has delirium. So, we need to implement
a screening tool!” Your administration also needs a precise list of reasons to consider
a Geriatric ED that can be clearly and consistently communicated.
The completion of the sentence, “we need a Geriatric ED because . . .” needs to include
contributions from multiple stakeholders to capture the range of motivations. Responses
should be solicited from hospital administrators, ED leadership, ED nurses, and other ED
clinicians and staff. It is extremely powerful if you can also include the voice of user groups
such as older patients or community representatives. Your ED or hospital may have
a patient advisory panel. Can you engage with the local Alzheimer’s association or an
organization that provides community-based care or a residential care facility for their
perspectives on care for older people in your ED?
Box 2.1 Holy Cross Hospital, Senior Emergency Center
The year was 2007. Kevin Sexton, CEO of Holy Cross Hospital, gathered his executive team
together to share a personal story about the painfully poor emergency care his own
mother had just received in her local ED. Determined to make sure his own hospital did
not treat older patients similarly, he charged his team to immediately take action.
Recruiting Bonnie Mahon, a nurse leader from their successful Senior Services program,
to partner with the ED medical director proved the starting point for a multi-disciplinary
team. A tight eight-month timeline and the hospital foundation’s pledge of $150, 000 for
renovations provided the team the spark needed to design, build, and staff the first-in-the-
nation senior emergency center. With geriatrician Bill Thomas and gerontologists from the
local University of Maryland, Baltimore County to provide ongoing training and research,
the Holy Cross team met the challenge with their reimagined emergency care for older
people opening its doors in September 2008.
A common impetus for change to a Geriatric ED model is a sentinel event in the ED –

a dramatic or high-profile negative event in the care of an older ED patient. More than one
hospital has started moving toward a Geriatric ED simply because the mother of the CEO or
the local mayor had a bad (meaning “typical”) experience in its ED! While all negative
events are regrettable, they can be a strong catalyst of change. Root cause analysis of them
may suggest the need to change processes or personnel and those changes may align well
with a Geriatric ED. Identifying such ED organizational “pain points” from ED staff
members can also inform future direction of change in the ED (see the earlier truth-
mapping exercise). To quote Churchill’s famous dictum of change management, “Never
let a good crisis go to waste!”
At the hospital’s organizational level, the motivation for making a change may also be
found on an ED’s or hospital’s data dashboard. Key dashboard indicators include:
• What is the trend of your overall ED satisfaction scores? And, specifically, for your older
ED patients?
• What is the trend for older patients’ ED length of stay?
• Is the number of older patients boarding in the ED increasing or decreasing over time?
• What is the trend regarding unaccompanied nursing home patients arriving at your ED?
Assessing your ED dashboard focusing on patients aged 65 and older may reveal actionable
insights that will drive and support Geriatric ED change.
There is a wide range of motivations for exploring a Geriatric ED model. You’ll find
them. The key is to document those motivations and to be intentional about developing
them into sustained action toward measurable goals and ED outcomes. The next section
begins to explore the process of moving from a motivation to concrete changes in the ED.
How Might We Create Our Geriatric ED?

Once a hospital’s reasons for starting a Geriatric ED are articulated, hospitals may move to
the next step of using a “How might we?” type question to generate a range of potential
actions they could take for their Geriatric ED. The “How might we?” question comes from
a “design thinking” tradition with a goal of articulating a broad set of potential solutions to
a problem area under study [11]. For example, an ED may ask its stakeholders “How might
we restructure the ED to better care for our older adult patients?” This open-ended question
gives you and your team the creative freedom to address specific problems that you have
identified in your own reasons for change.
And Who Is the “We” Anyway?

In healthcare and other organization settings, the movement from a set of ideas or aspir-
ations to organizational change is frequently facilitated by one or more “champions.”
Champions are influential members of an organization who can help drive change. In the
hospital setting, the champion model has been successfully used in hospital quality improve-
ment efforts, in areas from increasing handwashing rates to decreasing Caesarean section
rates [12].
Identifying a group of Geriatric ED champions is a critical step in transforming existing
ED structure, processes, and outcomes in the development of a Geriatric ED. A review of
current Geriatric EDs suggests there are at least five types of champions who may
be involved as change agents, including the (1) hospital executive champion, (2) ED
physician champion, (3) ED nurse champion, (4) geriatric medicine champion, and (5)
community champion. While we list them individually in Table 2.1, there may be overlap
between them (the nurse who is the champion may also be the VP of Nursing) and not all of
them will be involved in any Geriatric ED site. If you can get even two champions involved,
then at least you have the beginning of a team.
Table 2.1 Geriatric ED champions
1. Executive champion
2. Physician champion
3. Nurse champion
4. Geriatric medicine champion
5. Community champion
Executive Champion
It is nearly essential to have some support from the executive leadership of the hospital.
Unless your project is championed by a senior executive leader and aligns with hospital
priorities, it is unlikely you’ll make progress beyond the most minimal of changes.
Typically, the executive leader identifies geriatric emergency care as a priority and
supports the ED clinical leadership to implement an improvement effort. They probably
will not be involved with the subsequent Geriatric ED implementation process in a hands-
on way. However, they will serve as an administrative liaison with the ED department
leadership, will bring credibility to the project, and will advocate for financial and
personnel resources.
Physician Champion
Geriatric EDs can develop through the advocacy of one or more ED physician champions.
The physician champion recognizes the increasing number and complexity of their older
ED patient mix and its impact on the ED environment. At the clinical level they recognize
the need to modify ED processes to improve the care of older ED patients and families.
These ED physicians begin to look for different approaches, resources, and training to
address their needs.
The ED physician champion may be the director of the ED, more likely an
individual ED physician in the group. Support of the ED medical director is essential.
The ED physician champion has the benefit of peer-to-peer physician interactions to
influence and hear the perspective of the physician group. Enthusiasm from a physician
champion is valuable in developing a shift in attitude and culture among all physicians
to support a Geriatric ED. In some settings, developing this role may be complicated by
the fact that ED physicians are often not hospital employees but are part of a contracted
ED physician group. In some cases, it may be necessary to develop a supplemental
compensation procedure for the work a physician group commits to the Geriatric ED
efforts.
Nurse Champion
As patient advocates, nurses are at the forefront in efforts to create Geriatric EDs. With
their hands-on clinical experience, ED nurse champions can advocate forcefully and
effectively for implementing practice and system changes. Organizationally, ED nurse
champions have the advantage of being hospital employees so fall more easily into the
organizational chart of change. Equally importantly, they are well placed to influence the
ED staff nurses who are key people to win over in efforts to change practice and culture. In
the clinical setting, ED nurses are the ones who spend the majority of the time with the
patients. They can be the greatest force or the greatest impediment to implementation of
a Geriatric ED.
Geriatric Medicine Champion

Another source of support may be the hospital’s department of geriatric medicine.
Geriatrician champions bring essential clinical expertise and institutional connections
that are indispensable for teams redesigning ED care. Geriatricians generally see
improving care of older people in all settings of the hospital system as part of their
mission. Leaders from geriatric medicine can serve a valuable educational and con-
sultative role. One early-adopter Geriatric ED engaged its geriatricians to do weekly ED
rounds to articulate key issues in the acute care environment. Those rounds by the
geriatrician identified “at risk” older patients and added valuable teachable moments to
the Geriatric ED. A geriatric medicine champion may add a lot to developing geriatric-
specific processes in the ED and in improving transitions of care that are essential to
the processes of the new Geriatric ED. While ED change is certainly possible without
the involvement of geriatric medicine champions, the outcomes are almost always more
robust with their support.
Community Champion
In some cases, community members or leaders of aging advocacy groups recognize the
emergency care needs of the growing older population and can forcefully advocate for
a Geriatric ED. Community champions may approach the hospital leadership, the
hospital board of directors, or the hospital foundation to support a Geriatric ED.
Beyond providing the initial motivation, a community champion can also be a valuable
connection to the full range of services in the local aging care network with which EDs
are often not familiar.
The combination of knowing (1) what is important to your hospital, (2) what the truths
are about your ED’s current care of older patients, and (3) the advocacy of your Geriatric ED
champions leads to the transformational momentum needed to create a Geriatric ED.
Synthesizing this self-knowledge and gathering the Geriatric ED champions typically
provides energy and direction.
What Will Your Geriatric ED Look Like?

The final section of this chapter explores the decision regarding what your Geriatric ED will
look like: a separate space? Or fully integrated into the main ED?
Box 2.2 University Hospitals of Leicester ED Frailty Unit
In Leicester, UK, Drs. Jay Banerjee (emergency physician) and Simon Conroy (geriatri-
cian) have pioneered a unique version of the Geriatric ED called The Emergency Frailty
Unit. In 2015, they noticed that the ED Decision Unit was full of older people about
whom no one was making a decision. They took that 16-bed unit and developed
a shared-care model where medical care was provided by both ED and geriatrics. As
they say, “these patients need both sets of skills” – the acute rapid decision-making
and knowledge of trauma and injury and acute illness; and the more holistic consid-
eration of frailty-attuned attitudes to polypharmacy, cognitive assessment, and goals
of care conversations. As the two interdisciplinary teams worked together, they
developed a strong alliance. Now the geriatric team also extends into the main ED
where they can have an impact beyond the few patients in the Frailty Unit, but also
for all older patients by infusing principles of frailty and complexity into daily ED
practice. Hospital admissions from the ED have dropped by 10%, as have early ED
returns. Part of their success has come from working closely with their community
partners so that post-discharge care is also coordinated.
Figure 2.1 Drs. Conroy (left) and Banerjee
To date, hospitals have developed a range of different interpretations of what a Geriatric

ED looks like in their own locale. By “looks like,” we reemphasize that we don’t mean just
the physical appearance, space, and layout. We mean all the people and processes that
function in those spaces. Geriatric EDs vary widely [13]. However, despite that variability,
Figure 2.2 shows the relationship between the three essential elements of a Geriatric ED
model that we call “the 3 Ps,” for Geriatric ED people, processes, and place. We will expand
on each of these elements in Chapters 5, 6, and 7. They map closely onto the Donabedian
quality improvement constructs of structure (the context within which care takes place, that
Figure 2.2 Geriatric ED people, processes, and place

is, people and the environment of care) and process (the interactions that determine care,
that is, protocols and policies). In developing a Geriatric ED, the people staffing it always
come first: They define what the Geriatric ED will be and how it will function. With the
initial people identified, you begin to consider the physical design: Will the Geriatric ED be
its own separate space? Or will it be integrated into the main ED space? These decisions
regarding people and place will inform the development of processes, protocols, and policies
that determine how care will be different in this place.
Early Design Decision: Separate Space or Integrated Space

Approach?
Based on several surveys of current Geriatric EDs, there are two principal physical space
approaches that we identify as the (1) Separate Space and (2) Integrated Spaces approaches
as seen in Table 2.2 [13,14]. Importantly, beyond the different physical space, the two
approaches are indistinguishable in their common focus on staffing, training, policies,
and procedures focused on optimizing the ED care of older patients. People and processes
remain the same, no matter what physical space they are delivered in.
Table 2.2 Approaches to the Geriatric ED space
1. Separate Space
2. Integrated Space
a. Every ED bed is a geriatric bed
b. Specified ED beds are geriatric beds
c. Geriatric-focused ED observation unit
Separate Space Approach

Some of the earliest examples of Geriatric EDs envisioned a purpose-built, completely
separate, and dedicated space for older ED patients [15]. Such Geriatric EDs paralleled
the design of pediatric EDs that developed in the 1970s with separate physical spaces
adjacent to the main adult ED. In the Separate Space (SS) approach, the physical environ-
ment, personnel, policies, and procedures are modified to address the unique issues of older
adult ED patients and “segregated” in one area, often physically separate from the main ED.
The purpose-built SS Geriatric ED is a physically separate space with staff who are trained in
geriatric care including emergency physicians, geriatric nurse practitioners, nursing staff,
and geriatric social workers as well as access to geriatric trained pharmacists, physical
therapists, and other geriatric medicine consultants. Key advantages of the purpose-built
SS approach include enhanced control over the staffing, processes, and environmental
conditions (e.g., noise, activity, mobility, accessibility, equipment) and dedicated geriatric
trained staff. The closed SS, geriatric focus, and geriatric clinical training may lead to
improved diagnostic accuracy, improved identification of delirium, more familiarity with
polypharmacy situations, avoidance of medications with known adverse side effects for
older adults, and decreased hospital admissions and ED readmission rates.
The SS approach with its Geriatric ED-trained staff can focus on developing, revising,
and implementing key policies and processes related to optimal operation. These policies
may include the hours of operation, admission criteria, triage procedures, geriatric screen-
ing tools (e.g., delirium, cognitive impairment, falls history, polypharmacy), restraint use,
medications, discharge procedures, and postdischarge follow-up.
There are several disadvantages to the SS approach. It imposes a certain space inflex-
ibility on the overall ED: its occupancy varies with the fluctuating number of older people
arriving at the ED. In EDs where space is at a premium (i.e., all of them!) the geriatric
space often becomes “available real estate” when the ED is in surge mode, leaving the space
unavailable for older patients. Staffing can also be a challenge as emergency nurses who
chose that specialty may not want to spend their days seeing only older patients. There is
a real concern about de-skilling of the broad range of ED skills if staff are seeing only one
cohort of patients. Anecdotal evidence suggests that some hospitals originally using SS
Geriatric ED models are reassessing how the space could be optimally utilized, particu-
larly in the context of chronic overcrowding in the ED [13]. Other hospitals have
implemented flexible admission criteria to allow this space to be utilized by other age
groups when periods of demand fluctuate. The evolution of the SS approach will be
important to track.
Integrated Space Approach

To date, a relatively limited number of American and international Geriatric EDs have
opted to allocate dedicated space to create an SS model. The majority of Geriatric EDs
operate by providing geriatric-focused services within their main ED in some fashion. We
notice a few versions of the Integrated Space (IS) approach where the care of older ED
patients is intentionally integrated into general ED operations. The classification of IS
includes at least two configurations: (1) every ED bed is a geriatric bed and (2) specified
ED beds are geriatric beds.
Every ED Bed Is a Geriatric Bed

Likely the most effective and sustainable approach (unless you have the resources to create
and staff a separate space) is to make every bed in the department a “geriatric bed” and to
deliver your processes to older patients wherever they are in the ED. This variation allows
complete flexibility regarding which beds older patients occupy. It requires no new construc-
tion of the department’s physical space and fewer modifications of workflow. Disadvantages
are that it doesn’t allow optimal lighting and noise reduction, flooring, beds, or accessibility.
Those things – “wants” not “needs” – can be added in your next ED redesign.
Specified ED Beds Are Geriatric Beds

This IS approach identifies specific Geriatric ED beds within a defined area of the ED. For
example, one ED designated a set of five beds closest to the nurses’ station as its geriatric beds,
allowing closer monitoring. Such a configuration within the main ED may be organized with
many of the features of an SS approach including some of the physical environment elements
like upgraded hospital beds, lighting, flooring, and noise abatement. While the designation of
Geriatric ED beds within the main ED does not allow for complete control of the physical
environment, it does hold many of the same advantages included in the SS approach. But
anyone who works in an ED will recognize its clear practical problems. You may designate five
beds as “geriatric.” But what happens when the department is busy and there are only four
older people registered? Obviously the fifth bed is taken by another patient. And then what
happens when a fifth older person arrives 15 minutes later? The reality of bed-pressure needs
to be integrated into planning. This model allows much less flexibility.
Geriatric-Focused ED Observation Unit

Some American EDs have created “observation units” within the ED to conform to
Medicare billing requirements of monitoring for 23 hours before triggering an inpatient
fee code. Some have further experimented with making those observation units into an
exclusively geriatric space [14]. This unit functions as a location that provides increased
monitoring of patients to evaluate safe discharge planning. Such units can flexibly incorp-
orate many elements of a Geriatric ED and may potentially better serve a patient population
that would have previously been admitted to the hospital.
Conclusions
In this chapter, we’ve pointed you to some sources of guidance – The Geriatric ED
Guidelines, the GEDI Toolkit, and Geriatric ED Accreditation criteria – to act as inspiration
for your project. We’ve addressed thinking about what is important to your ED and
hospital, including taking a close hard look at your current ED reality and older patients.
We’ve suggested some key data analysis you can conduct – from the obvious (how many old
people come to your ED?) to the less obviously important (how often do you use restraints
on old people?). We have discussed how to analyze in terms of structure and process what
you already have that are useable in your new Geriatric ED – people, policies, and
environmental and physical attributes. We have encouraged you to think about the key
people you need to support this initiative, to champion this change. And finally, we have
sketched some general approaches you can take – the Separate Space approach versus the
Integrated Space approach – to create your new Geriatric ED.
But no one ever said this would be easy! The next chapter on overcoming resistance will
address some bumps along the smooth road, specifically, the naysayers who respond to all
your good proposals with, “Yeah, but . . .”
Medicine. CJEM. 2018/01/23ed. 5;20

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Chapter
Overcoming Resistance: What
to Do with “Yeah, But. . .”
3
To most people reading this book who work in EDs, it likely seems obvious and compelling
to make small and big changes to improve care for older patients. But to do this, you’ll need
to be ready to address the resistance of those who don’t see things the same way. This
chapter is aimed at helping you be as persuasive as possible in advocating for change.
The most common kinds of criticisms and opposition to creating a Geriatric ED fall into a few
main themes. You’ll have to respond to these predictable pitfalls with passionate and convincing
arguments of your own. So, you’ll need another “elevator pitch” – a brief but compelling sales job
you can deliver when you find yourself responding to the inevitable naysayers.
In this chapter, we’ve grouped the main opposition into several themes. We’ll look at
each of them in turn – and help you craft some concise, cogent replies.
Maintaining the Status Quo: “Yeah, But . . . We’re Doing Just

Fine As We Are”
Everyone loves change . . . until it happens to them! A basic instinct for individuals and
institutions is to maintain the status quo: It’s easier, simpler, and, apparently, cheaper. We all
know that when we start disrupting the status quo, then many other things have to change too.
We have to alter our behaviors and attitudes and even the way we think of ourselves.
There is the possibility of conflict.
When confronted with the idea of changing the way things are done in the ED, clinicians
and leaders will often claim, “but we’ve always looked after old people! And I thought we did
a pretty good job, just like with all our other patients.” This is comforting and reassuring.
Maintaining this attitude helps the individual and the institution to protect themselves from
an uncomfortable acknowledgment that, just perhaps, things are not as good as they could
be [1]. Sometimes it feels better to . . . just say “no” or “not right now”!
This attitude is sometimes based in a misperception that the world outside the ED is
constant and static. It’s often helpful to point out that EDs are built to serve their
communities. The community beyond the door of the ED is likely radically different from
even 10 years ago. While everyone knows generally that societies are aging, many don’t
know that that change has accelerated just since 2010. That’s the year that the first of the
baby boomers entered “young old age” at 65. Now they’re already over 75 . . . and counting.
As the American Geriatrics Society tells us, 10 000 Americans turn 65 every day. They’re
the fastest-growing demographic in most countries. The crest of that silver wave will peak
around 2030 when nearly one in four people in your community will be over 65 – and
probably one in three patients in your ED. Your colleagues, and your boss, need to know
that the number of people who are living longer and living with more social and medical
32
Overcoming Resistance: What to Do with “Yeah, But…” 33
complexity is increasing daily. The time for making changes to accommodate them was
yesterday. But today will do. A few years from now is leaving it much too late.
If it’s done tactfully, you may be able to question your colleague’s assumption that your
ED is already doing the best job possible for all of its patients (remember that conversation
with your CEO in Chapter 1?). In doing this, it might be helpful for you to be familiar with
your department’s patient satisfaction ratings (if those are available) and to see if there is any
segmentation by age group. There is some evidence that older people often leave EDs
dissatisfied with a number of things: They feel that their main worries have not been
addressed, that their care has been superficial, and that they don’t know what is supposed
to happen next [2,3]. Also, the evidence persistently shows that EDs are not very good at
detecting delirium in older patients, that sepsis outcomes are consistently worse in older
patients, that older people receive less analgesia, and that trauma mortality and morbidity
outcomes are poorer in older patients [4].
Finally, going back to the “ground truth” in Chapter 2, you just have to ask around in
your department to find out what staff think about the status quo. You’ll probably hear,
“Yeah, it sucks for older patients. Everybody knows that we need to do something different.”
So, maybe we’re not doing “just as fine” as we think we are?
Focusing on Perceived Obstacles: “Yeah, But . . . We Don’t

Have Enough __________ (Fill in the Blank): Time, Money,
Expertise, Leadership”
When most folks are first introduced to a new concept, they tend to find a lot of good
reasons for not adopting it. With Geriatric EDs, the most common reasons are a perceived
lack of time, money, or leadership. As a “change agent” (a newfangled code term for “rebel
with a cause”) you may need to demonstrate that your site has more of all of those things
than is thought. And that there’s more to gain than there is to lose.
The “Lack of Time” Obstacle

There is a general assumption that providing a different kind of care for older patients will
necessarily take more time than what you are already doing. There are all those extra people,
doing more assessments, expanding your investigations, connecting with other people. It
has to take more time, right? This objection recalls the famous aphorism attributed to the
basketball coach, John Wooden: “If you don’t have time to do it right, when will you have
time to do it over?”
Every person associated with healthcare – clinicians and administrators – knows that doing
a good job the first time saves time and often saves lives. It is fairly easy to make the argument
that, in a high-quality ED (which we all want to be part of), there will be a strong support for
getting it right the first time. But don’t over-sell, just over-deliver. Point out that the extra people,
assessments, investigations, and attention to transitions of care can be linked to more accurate
diagnoses, avoided admissions, fewer early returns, and greater patient, caregiver, and staff
satisfaction. Most departments that have implemented Geriatric ED changes report improve-
ments in all of those metrics, even though it may take more time to get it right in the first place.
But how much time are you willing to spend in order to increase your identification of
delirium or decrease its incidence? How many bed-days would be saved by your hospital by
avoiding one case of incident delirium per month? How many bounce-backs – which are
dangerous, embarrassing, and expensive – could be prevented by identifying a patient’s level

of frailty and social support before making the discharge plan? If your interdisciplinary team
can prevent even one unnecessary admission each day, your ED can improve patient flow
and decrease patients held in the ED and free up in-hospital beds. Patient after patient,
and day after day, multiplying these impacts can have a deep effect on time saved, not spent,
and on the bottom line for your ED and hospital.
It’s important not to “over-sell” your case. It’s true that individual assessments may take
longer, but the cumulative effect of “getting it right” more of the time, and having to “do it
over” less of the time, is clearly real time-efficiencies that your Geriatric ED can deliver to
your hospital.
The “Lack of Money” Obstacle

A reflex argument against the Geriatric ED is that there isn’t enough money to make all
those changes. EDs never have unlimited budgets, of course. But, interestingly, many of the
costs associated with the changes suggested in Chapters 5, 6, and 7 do not represent much
expense. They are mostly not associated with doing a lot more, just doing a lot differently.
A classic example of doing things differently relates to accessing an interdisciplinary assess-
ment. In many EDs the only thing preventing a patient from being discharged is the need for
a mobility and functional assessment, because the ED physician is uncertain whether the patient
is safe for independent living at home. But oddly, in many hospitals, the only way to access an
assessment by a physical therapist (PT) or an occupational therapist (OT) is by admission to the
hospital! However, it is the same human resources cost to have a PT or OT assess that patient in
the ED as it is after a hospital admission. Developing a system to add access to a PT or OT or
social worker or pharmacist in the ED doesn’t cost more; it just shifts the location of the expense.
This also demonstrates why these Geriatric ED changes are best thought of as a whole-hospital
project supported by senior leadership, rather than just an in-ED activity.
Probably the most cost-intensive addition to a Geriatric ED would be developing the role of
nurse-led geriatric care coordination. For most departments, this new staff position represents
significant costs of hiring, training, and salary. In other, larger departments, it merely means
repurposing a case manager or resource nurse to focus exclusively on older patients.
You can make the case to a forward-thinking administrator that costs are not measured
purely in quantitative monetary units. Costs and benefits can also be measured in extended,
less tangible units. Reputational enhancement, capture of market share, philanthropic
contributions, increased social capital of the hospital within the community, and improved
staff wellness with better recruitment and retention – these are all valuable gains that keep
providing returns over a long period.
The “Lack of Leadership and Expertise” Obstacle

Some people working in the trenches of the ED, seeing a rising number of increasingly
complex older patients daily, may perceive that they are the only ones aware of the
possibility of improvement. A common reaction is that “nobody else cares: leadership
won’t do anything!” Yet ED and hospital leadership are “in the business” of making
improvements in their offerings especially to their largest consuming population.
Staff on the front line may need to be reminded that proactively suggesting improvements
will likely be met with a much warmer reception than reactively complaining about bad
outcomes. The leadership for Geriatric ED change may come from “above” – the visionary
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used except in emergencies; it is not regarded as a satisfactory
permanent plan of water treatment.
258. These housing regulations now provide, as a rule, that
houses designed to accommodate more than two families shall not
occupy more than two-thirds of the lots upon which they are built, the
remaining space being left for light and air. They also require that
such houses shall not be of highly inflammable construction, that
they be provided with lighted hallways, that sanitary equipment be
installed, and that no rooms be used for ordinary living purposes
unless they have one or more windows. A further provision in some
of these tenement-house laws is that houses may be condemned as
unsanitary if they contain less than so many cubic feet of air space
for each person living in them. This last provision is difficult to
enforce except by frequent inspection, yet it is very important
because no matter how well a house may be constructed, there will
be a danger to the public health if it is seriously overcrowded.
259. At the Peace Conference in 1919 the protection of the public
health throughout the world was considered so important that
provision for it was included in the Covenant of the League of
Nations (see p. 638).
260. An exception to this must be made in the case of the negro
population of the South. The amount of poverty among the Southern
negroes is large, although most of them live in rural communities.
261. Poverty, in a way, reproduces itself. Some years ago a New
York social worker gave the following rather cogent description of the
way in which one generation passes its poverty on to the next. “A
child, reared in a poor home, is taken out of school and sent to work
at an early age. He drudges away, brings home every cent of his
pay, is allowed to keep little or none of it, and gets no fun out of life.
After a while he gets tired of this; he meets some girl who has been
brought up in the same way; they get married; but neither of them
has saved any money nor has the slightest idea of how to manage a
home. They rent a small flat, buy some furniture on the installment
plan, and then find that they are not able to pay for it. They get into
debt and when either falls sick or the husband is out of work there is
nothing to eat. When children come they grow up on improper
nourishment; they are slapped in the face and scolded at all hours;
they get no home training and very little schooling; as soon as they
are able to earn a few dollars a week they are hauled out of school
and put to work—and so history just repeats itself.”
262. The marriage of feeble-minded or other mentally defective
persons ought to be prevented, for the results of such marriages are
bad for the whole community. They help to fill the poorhouses, the
asylums, and the jails. There are some who believe that the
government ought to go further and lend its influence towards the
promotion of greater care in determining the marriage of persons
who are not mentally defective. Marriage, as has been shown in an
earlier chapter, is the basis of the home and hence the foundation of
the whole social order. It is an institution of exceedingly great
importance to the well-being of society. Yet we leave the whole thing
to the caprice of individuals, or their passing fancy, or to the
accidents of chance friendships. Whatever may be the inspiration to
marriage it can truly be said that many unions of man and woman
contribute nothing to the well-being of present or future society. Is it
right that an institution of such importance to the human race, both
present and future, should be so little controlled by law, by custom,
or by public opinion and so largely left to the discretion of
individuals? Can the race be improved in that way? Beyond
preventing the marriage of mentally degenerate persons is there any
further action that society ought to take?
263. Many explanations are offered for this. We are a relatively
new country, with a population made up of many races. Court
procedure is slow and cumbrous; it takes a long time to punish
offenders, and they have a fair chance of escaping punishment
altogether. Police have been under the control of politicians and
have been lax in enforcing the laws. We have emphasized the idea
of liberty so strongly that it has benefited even the criminal. We have
not made punishment certain enough or severe enough to deter
people from evil-doing. All these excuses have some force, no doubt,
but do they fully account for our poor showing in comparison with
other countries?
264. The reformer who first educated the public to this doctrine
was Jeremy Bentham, an English writer on social topics who lived in
the early years of the nineteenth century.
265. The most conspicuous figure in this branch of prison reform
during recent years is Mr. Thomas Mott Osborne, who was for a time
in charge of the state prison at Auburn, N. Y. Mr. Osborne entirely
abolished the old system of discipline and established a scheme of
self-government among the prisoners. But public opinion was not
quite ready for such a radical experiment as Mr. Osborne
inaugurated, and his work was bitterly criticised in many quarters,
although it was commended in others. In the midst of the controversy
he gave up his post and his successor did not continue his policy.
266. A good many people are beginning to wonder whether the
reaction against the old-fashioned methods of dealing with offenders
has not been carried too far. Persons charged with crime are now
given a fair trial with liberal opportunities for appeal. When convicted
they are frequently given indeterminate sentences and then, after a
short term of confinement, are released on parole. In prison they are
well housed, properly fed, given various privileges, provided with
motion picture entertainments, and given other forms of recreation.
The complaint is made that we have made the path of the
transgressor altogether too easy and that the sort of punishment
which is now meted out to offenders is inadequate to serve as a
deterrent to crime. The increase in crime, particularly in the larger
American cities, is by some attributed to this leniency of treatment.
267. One of the first of these courts, and the best known of them
all, is the Juvenile Court of Denver, Colorado, which was for some
years presided over by Judge Ben B. Lindsey. For a time the
success of this court seemed to be remarkable, for Judge Lindsey
possessed the knack of getting wayward boys to tell him the truth;
but in his zeal for giving them a chance to reform he appeared to
many citizens of Denver to be unduly lenient. The Juvenile Court
was retained, but another judge was put in charge of it.
268. In number of divorces the United States, unhappily, leads the
world. More divorces are granted each year in this country than in all
other civilized countries put together. This is one of the things which
gives us no occasion for boasting, because it points to a serious
weakening in the stability and strength of the family as a social unit.
Not only is the number of divorces very large, but it is rapidly
increasing year by year. Fifty years ago the number per annum in the
United States was only about twenty thousand; now it is over one
hundred and twenty thousand. On the average there was one
divorce for every thirty marriages in 1870; today the ratio is one in
ten. At the present rate of increase it has been estimated that by
1950 no fewer than one-fourth of all marriages will be terminated by
divorce, and if the same condition of affairs should continue until the
end of the twentieth century, one-half of all the marriages would
eventuate in that way. This would indeed be an ominous outlook
were it not that conditions are likely, sooner or later, to undergo a
change. When a social problem becomes very serious, as this one is
now becoming, it is the habit of society to seek out and apply
appropriate remedies.
269. Since its foundation in 1788 the national government has
spent, in round figures, about sixty-seven billion dollars. Of this entire
sum fifty-eight billions have been spent for war, that is, for
maintaining the army and navy, for carrying on the nation’s various
wars, for pensions, and for interest on war debts.
270. Theodore Roosevelt, Fear God and Take Your Own Part
(N. Y., 1915), Ch. I.
271. History is full of examples to support this statement. When
Carthage proved unable to defend herself against Roman
aggression, the victors left not one stone upon another. Look at
Poland, ripped apart during the seventeenth and eighteenth
centuries by her avaricious neighbors and now restored to
nationhood by the armed forces of France, England, Italy, and
America. And what of China today? Are her four hundred million
people happier and more prosperous because they happen to be
citizens of a defenceless country?
272. The War of Independence was won by a volunteer army. On
the conclusion of peace this army was disbanded, but the absence
of a defence force was deemed a serious danger. Accordingly, when
the constitution was framed in 1787, it provided that the new
Congress should have power “to raise and support armies.” During
Washington’s first term a Department of War was established in the
national government and a small regular army was created under the
supervision of this department. The size of this army was not above
five thousand men of all ranks, barely sufficient to keep the Indian
tribes from giving trouble. But the Napoleonic wars in Europe led
Congress to increase its size as a measure of precaution, and during
the War of 1812 an endeavor was made to raise the regular army, by
enlistment, to about 35,000 men. Recruits, however, did not come
readily because the war was unpopular in some parts of the country,
and it therefore became necessary to call out the militia
organizations of the several states. After 1816, when peace was
made, the regular army was greatly reduced, and until 1860 it
remained small with the exception of the years in which the United
States was at war with Mexico. The Civil War necessitated a
considerable expansion of the regular army, but the larger portion of
the fighting force was obtained by calling out the state militia and by
raising regiments of volunteers. When the war was over, Congress
fixed the maximum strength of the regular army at 25,000, and there
it remained until the outbreak of the war with Spain, when it was
more than doubled. In 1916, during the World War, but before the
United States entered the conflict, a further increase to a maximum
of 175,000 was authorized. This figure subsequently rose to 225,000
but in 1921 it was cut down by Congress to 150,000, at which point it
remains today, although a further reduction is now being considered.
273. Prior to 1916 the national guard could not be called upon for
service outside the United States, but only for defence against
invasion and for the suppression of internal disturbances. But in
1916 it was provided by the National Defence Act that whenever
Congress authorizes the use of armed forces in addition to the
regular army, the President may draft any or all members of the
national guard into the service of the United States and may employ
them outside American territory.
274. Theodore Roosevelt was serving as Assistant Secretary of
the Navy when the war with Spain began in 1898. He offered to raise
a volunteer cavalry regiment of cowboys from the cattle country and
his offer was accepted by the government. Resigning his position in
the Navy Department he organized this regiment of Rough Riders
and became its lieutenant-colonel. The Rough Riders went to Cuba,
where they gave a good account of themselves.
275. The actual organization and disciplining of the army during
peace, as well as its movements and operations in war, are under
the immediate direction of the General Staff. This body consists of a
Chief of Staff, who is appointed from among the high officers of the
army, and numerous other army officers who are detailed for this
service. The General Staff is so organized that in the event of war
one section of it can take charge of operations in the field while the
other keeps building up the army at home. General Pershing, who
commanded the American Expeditionary Forces in the World War is
now Chief of Staff, his principal assistant being Major-General
Harbord, who commanded the First Army overseas.
276. For minor offences an enlisted man is tried by summary
court-martial before a single officer. For more serious offences a
special court-martial of from three to five officers is convened. If the
offence is very serious, or if the accused person is a commissioned
officer, the trial takes place before a general court-martial of from five
to fifteen officers, who must be, wherever possible, at least of equal
rank with the accused. The verdict, or finding, of the court-martial,
together with its recommendations for punishment in case of
conviction, is transmitted to the officer by whose order the court was
convened. This officer has power to diminish but not to increase the
punishment recommended by the court-martial.
277. There is still another phase of military jurisdiction which must
be distinguished from both military law and martial law. This is called
military government. It may be explained as follows: When any
territory is conquered and held by an invading army it must obviously
be given some temporary form of government. The former
government usually flees and something must be put in its place.
Under such conditions the commander-in-chief of the occupying
force sets up a temporary administration. In 1919, when a portion of
the American Expeditionary Force advanced into German territory
under the terms of the armistice, a military government with its
headquarters at Coblenz was established for the area occupied by
the American troops. A military government may even be set up in
home territory during a civil war or insurrection. After the fall of the
Confederacy military governments were maintained in the South until
the state governments were reconstructed, hence we commonly
speak of the “reconstruction” period. Military government is always a
temporary arrangement, never intended to be permanent, although it
may last for several years. It does not, like martial law, supplant the
ordinary laws of the occupied territory, but merely means that the
occupying army, through its commander-in-chief, takes over the
administration.
278. The beginnings of the American Navy go back to the time of
the Revolutionary War, when a few frigates were placed in service;
but when the war was over these ships were sold and the navy
abolished. In 1794, however, Congress authorized the building of six
new frigates, and four years later a Department of the Navy was
created, with a member of the Cabinet at its head. The number of
vessels increased very slowly and when the War of 1812 began the
United States had only sixteen war vessels, some of them too small
to be of great usefulness. This small navy, nevertheless, gave a
good account of itself during the course of the war at sea. From 1815
to the outbreak of the Civil War little attention was paid to the
upbuilding of American naval strength, but during the course of this
struggle a great expansion took place. The invention of the iron-clad
Monitor revolutionized naval construction. But when the South had
been subdued the Navy was once more allowed to dwindle and it
was not until after 1885 that the United States again made a serious
attempt to build up a strong naval establishment. Since that date
naval progress has been steady and today the United States navy
ranks second in point of size among the sea forces of the world. By
the terms of the agreement concluded among the chief naval powers
of the world at Washington in 1922 it has been arranged that the
United States, Great Britain, and Japan shall each destroy certain
war vessels now built or in process of building, and that each shall
refrain from building new capital ships (except for purposes of
replacement), during the next ten years. At the end of this period the
navies of the United States and Great Britain will be approximately
equal in strength, while that of Japan will be about three-fifths as
strong. See also p. 577.
279. For the action of the conference with reference to matters in
the Far East, see p. 619.
280. Brigadier-General Mitchell of the United States Army Air
Service, in his testimony before a committee of Congress in 1920,
declared that a few planes could visit New York City and rain down
enough phosgene gas to kill every inhabitant “unless we provide
some means of repelling them.”
281. See the quotations from various military authorities given in
The Next War, by Will Irwin, pp. 46-66.
282. There is a tradition in England that if a person goes into Hyde
Park, London (a large open space in the center of the city), he may
gather a crowd around him and say anything he pleases, subject
only to the chance that he may be roughly handled if his hearers do
not like what he says. For this reason, Hyde Park is sometimes
referred to as the “safety valve” of the English government. Anyone
who has a grievance, real or imaginary, can go there and blow off
steam. Having had his say, without let or hindrance, the speaker
feels better about it. Somewhere in this country we ought to have a
Hyde Park.
We must be careful not to judge the liberties of the citizen and the
severity of a government by what may happen in war-time or in time
of civil insurrection. War inflames popular passion and impels both
the officers of government and the people to do unwise things,
sometimes to violate the laws of the land in the name of patriotism.
An excited nation, like an excited man, is entitled to some allowance.
Nevertheless, it is the duty of all who understand the meaning of free
government to stand firmly against the wrongful curtailment of
personal rights at any time; for the true interests of free government
are never promoted by resort to injustice or oppression.
283. This is a great and fundamental weakness of
international law, that there is no executive authority to apply
it and there are no courts to enforce its rules when nations
disobey. During the World War the rules of international law
were violated on many occasions, for example, in the use of
poison gas, the bombing of hospitals, the sinking of hospital
ships, the forcing of prisoners to labor on military works, and
the illegal detention of neutral ships. Yet in spite of these
violations international law emerged from the war stronger
than it was before. The nations which violated international
law most shamelessly were the ones that lost the war, and
their defeat was due in no small measure to the resentment
which was aroused throughout the world by reason of these
violations.
284. Illustrations are too fresh in everyone’s mind to
require any extended comment. In 1918 President Wilson
took with him to the peace negotiations at Paris no member
of the Senate. He did not keep in touch with the leaders of
the majority party in this body. But in 1921 when President
Harding appointed the four American delegates to the
Washington Conference he named two of them from the
Senate.
285. In addition to regular envoys, it is sometimes
customary for a country to send an unofficial representative
to conduct negotiations informally. During the years before
the United States entered the war, Colonel Edward M.
House, of Texas, was sent to Europe by President Wilson on
at least two occasions in order that certain confidential
discussions might be carried on without using the regular
diplomatic channels. When unofficial representatives are
sent in this way no public announcement is made.
286. Communications between diplomats and their own
governments are not usually sent by mail if the matters dealt
with are of great importance. They are sent by special
couriers or messengers. When diplomatic communications
are sent by telegraph or cable they are transmitted in cipher,
that is, in a secret code of words which no outsider can read.
Nations occasionally get hold of one another’s diplomatic
codes and decipher communications which they are not
supposed to read. For example, the German government in
the spring of 1917, before the United States declared war,
sent a wireless message to its official representative in
Mexico, telling him in substance that if America entered the
war, he was to stir up Mexico against the United States by
promising that when the war was over Mexico would be
rewarded with some American territory. This message was in
secret code; but the American officials caught it from the air,
deciphered it, and at the appropriate time put the German
government in an embarrassing situation by publishing the
message in plain English to the whole world.
287. When two countries go to war they at once withdraw
their diplomatic representatives from one another’s capitals.
The embassy or legation and its archives are put under the
care of some neutral ambassador until the war is over.
During the years 1914-1917 the American ambassador in
Berlin and the American minister in Brussels looked after the
interests of Great Britain at these two capitals. The work of
Mr. Brand Whitlock at Brussels was notable, and the services
which he rendered to the Belgian people during the years of
their country’s captivity will long be remembered in that
heroic little land.
288. In 1915, for example, the Austro-Hungarian
ambassador to the United States, Dr. Dumba, endeavored to
stir up trouble among certain Hungarian immigrants who
were working in American munition factories, making
weapons and military supplies for sale to Great Britain and
France. When the United States government discovered
these intrigues, Dr. Dumba was dismissed from the country.
289. The making of secret treaties continued, in fact, after
the war began. By secret treaties France and Great Britain
promised that Italy should have certain territories which were
held by Austria and that Russia should have Constantinople.
When the war was over the new government at Vienna
permitted the publication of a whole volume of secret treaties
that had been made during the preceding fifty years. The
Bolsheviks in Russia also published all the secret treaties of
the Czar that they could find.
In the covenant of the League of Nations it is provided that
every treaty between nations which become members of the
League must be registered and published.
290. There are some cases in which the approval of the
House of Representatives is also needed before a treaty can
go into effect. In the treaty which provided for the purchase of
Alaska in 1867 and in the treaty which closed the war with
Spain in 1898, provision was made for the payment of money
by the United States. Now no money can be appropriated
from the treasury without action on the part of the House,
and if the House had declined to appropriate the money, the
conditions of these treaties could not have been fulfilled. In
both cases, however, the House did actually vote the
necessary funds.
291. In 1870, for example, President Grant concluded with
the government of San Domingo a treaty which provided for
the annexation of that island to the United States. The
Senate, after a hard fight, rejected the treaty altogether. Even
more notable, of course, was the Senate’s action in declining
to ratify the treaty which President Wilson signed at Paris in
1919.
292. The English government proposed that the United
States and Great Britain should issue the declaration jointly,
but President Monroe and his secretary of state, John Quincy
Adams, thought it better that the United States should make
the declaration alone.
293. At the Peace Conference in 1919 the European
countries were willing to concede what was virtually a
recognition of the Monroe Doctrine, and the covenant of the
League of Nations contains a provision that nothing in that
document shall affect the validity of “regional understandings,
like the Monroe Doctrine, for securing the maintenance of
peace” (Article XXI).
294. Hiram Bingham, The Monroe Doctrine: An Obsolete
Shibboleth (New Haven, 1913).
295. No one knows exactly what it means today because
its scope has been rather indefinitely extended at various
times. No doubt it would be further extended if the occasion
should arise. For example, the original doctrine was directed
against European powers only. But if Japan should attempt
to acquire territory in Central or South America, the Monroe
Doctrine would unquestionably be invoked as applicable to
an Asiatic power as well.
296. Washington was well aware that the United States
might have to take a hand in European quarrels if they
should assume an extraordinary importance. Notice the
exact wording of the passage in his Farewell Address. “It
would be unwise in us to implicate ourselves by artificial ties
in the ordinary vicissitudes of her (Europe’s) politics, or the
ordinary combinations and collisions of her friendships or
enmities.” Washington was not in the habit of wasting words,
and he did not twice insert the limitation “ordinary” without
good reason. By the way, he did not use the phrase
“entangling alliances”. That expression was first used by
Jefferson in his inaugural address (March 4, 1801).
297. From 1815 to 1914 all the great wars were localized.
The Crimean War (1854-1855), although five nations took
part in it, was confined to the territories around the Black
Sea; the War of 1859, in which the French and Italians on the
one side fought the Austrians on the other, was settled in
Northern Italy. The other important wars were, for the most
part, individual duels between two nations or between two
sections of a single nation.
298. The total amount loaned to European governments by
the United States during the war was about ten billion dollars,
of which nearly half was loaned to Great Britain.
299. The payments made by Germany to Great Britain,
France, and Italy, as well as the payments made by these
countries to the United States, must inevitably take the form
of payment in goods. There is not enough gold in Europe to
make payment in gold. All this means that so long as the
reparations and loans are being liquidated large imports of
goods from Europe are likely to come into this country.
300. By the terms of a supplementary treaty, this does not
include the main Japanese islands themselves.
301. It is said that the Thirty Years’ War reduced the
population in some sections of the warring states to one-half
or one-third of what it had been when the struggle began.
The losses of all the countries engaged in the World War
have been estimated to be almost ten millions, more than the
entire population of Canada from ocean to ocean. Millions
more died from famine and under-nourishment at home. Is it
not strange that nations should work for years with might and
main to increase the size and prosperity of their populations,
then turn around and undo a large part of what they have
been able to accomplish? In peace nations labor to alleviate
each others’ distress; in war they labor to cause it. Patiently
through the decades men of science wrestle with the
problem of relieving pain and suffering; then, in an instant, all
their skill is devoted to killing, maiming, and suffocating men
by the million! There is no wisdom like the wisdom of man,
and no folly like it either.
302. The covenant was made an integral part of the peace
treaty, largely at President Wilson’s insistence, for two
reasons: First, because it was believed that this would be a
surer way of obtaining the assent of all the great nations to
the provisions of the covenant; second, because many of the
terms of the treaty (for example, those relating to boundaries
and mandates) were framed on the assumption that a
League of Nations would be in existence to carry them into
effect. Taken together, the treaty and the covenant make the
longest international document ever framed, a printed book
of 87,000 words—about half the size of this text-book. Nearly
a thousand diplomats, experts, and clerks spent more than
three months in drafting it.
303. Invitations were not extended to Germany, Austria,
Hungary, Bulgaria, Turkey, Russia, or Mexico. Austria,
however, has since been admitted to membership.
304. When, for example, a typhus epidemic broke out in
Poland, and the Polish authorities found themselves unable
to control it, the League sent a commission of health experts
to assist them.
305. This is because not only Great Britain herself but
India, Canada, Australia, South Africa, and New Zealand are
members of the League. It was assumed that the six British
votes in the Assembly would always be cast together; but, as
a matter of fact, the various British dominions insisted upon
having separate votes in order that they might vote according
to their own particular interests. In most international matters
the interests of Canada, Australia, and South Africa are not
at all certain to coincide with those of England.
306. Since the treaty and the covenant were joined
together, the objections to one applied to the other.
Concerning Shantung, see also p. 620.
307. The term “soviet” means council or meeting. The
constitution of the Russian Socialist Federated Soviet
Republic may be found in Frank Comerford, The New
World, pp. 281-305.
308. Nikalai Lenin is now the head of this Council; Leon
Trotzky is Minister of War in it. Each member of the Council
is head of a department.
309. The breakdown was due in part, no doubt, to the
disorganization wrought by the war and the internal revolts
which broke out in Russia after the war. To make matters
worse there were crop failures, with resulting famines, in
some of Russia’s best grain-producing regions.
310. It is quite true that some men and women work
because they like to work and dislike to be idle, or because
they feel that what they do is of value to the community, or
for some other reason not directly connected with their pay.
They form, however, a very small fraction of the total body of
wage-earners.
311. Voters.
312. Annulled by the Thirteenth and Fourteenth
Amendments.
313. Superseded by the Seventeenth Amendment.
314. See Seventeenth Amendment.
315. See Sixteenth Amendment.
316. Superseded by the Twelfth Amendment.
317. Modified by the Eleventh Amendment.
318. Compare Fourteenth Amendment.
319. The first ten Amendments, known as the Bill of
Rights, were adopted in 1791.
320. See Amendment XIV, Sec. 1, which extends part of
this restriction to the States.
321. Adopted in 1798 to protect the sovereignty of the
States.
322. Adopted in 1804, superseding Article II, Sec. 1.
323. Adopted in 1865.
Transcriber’s Note
The index entry regarding the duties of the Vice
President refers to a note on p. 270, but no such
note exists.
The index entry regarding compulsory arbitration
in New Zealand refers to a note on p. 419. The
note appears on p. 409.
Other errors deemed most likely to be the
printer’s have been corrected, and are noted here.
The references are to the page and line in the
original. Where the error is in a footnote, the
original note is included and the line within it.
71.32 protect a[rg/gr]iculture Transposed.
80.2 It wa[s] a long and grim Restored.
struggle
82.34 In the case of the Porto Added.
Ricans[,] citizenship
105.10 They are practical[ in] their Added.
nature.
179.33 and[ and] the county- Removed.
manager plans.
193.7 that i[s/t] encourages Replaced.
250.26 [I/i]t could act only Replaced.
316.13 many states[.] Added.
329.8 restocking of lakes with Added.
fish)[.]
353.33 The Non-Partisan League, Replaced.
pp.269-283[;/.]
379.33 and future development[.] Added.
418.10 a certain p[re/er]centage of Transposed.
the total
465.12 to the present taxpayers[.] Added.
468.n2.2 life of a public Replaced.
i[n/m]provement
470.10 Public Finance, [pp. ]261- Added.
280.
471.11 p. 457.[)] Added.
618.6 mastery of the Pacific[.] Added.
673.29 I do solem[n]ly swear Inserted.
683.6 a Senator or Inserted.
Represen[t]ative
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Introduction 1 7 Place: Addressing the Physical

Nurses Association, and Society for

Why Create a Geriatric ED?

Table 1.1 Common reasons: Why create a Geriatric ED?

1. The compelling business case

Box 1.1 Sample Elevator Pitch for Your CEO

The Compelling Business Case

The following argument is highly persuasive to your executive leaders. Unscheduled

Now Let’s Crunch Some Other Numbers!

• ED readmission rates for patients >65, >75, and >85

Box 1.2 Sample Elevator Pitch for Your CEO

You: Hello Freeman! Good to see you.

Geriatric EDs Have an Impact on Core Financial Metrics

Table 1.2 Questions for Geriatric ED business case discussion

1. How might a Geriatric ED impact our ED readmission rate?

Box 1.3 Mount Sinai Hospital Toronto

Figure 1.1 Nana Asomaning, Mount Sinai Hospital, Toronto

The “Ground Truth” of Improving Care for Older ED Patients

Table 1.3 Questions for ED staﬀ on challenges with older ED patients

The Increasing Number of ED Visits by Older Patients

Increased Number of Older ED Patients

Country Percent of Population Percent of Population

Increasing Proportion of Older Patients

Tectonic Drift or Seismic Shift?

Box 1.4 Sample Elevator Pitch for Your CEO

You: Hello Altaf!

4. Hwang U, Morrison S. The geriatric

8. Kennedy M, Ouchi K, Biese K. Geriatric 15. United Nations Population Division.

You’re Not Starting from Zero

What’s Important to Your ED? What’s Important to Your

Truth-Mapping Exercise: What’s True about Older Adults

• Disoriented, combative, older patients require a lot of nursing attention

What Do the Numbers Tell You?

Characterizing Your Older ED Patient Population

What about Your Structure, Processes, and Outcomes?

Your Current ED Staﬀ and Its Geriatric Competencies

Your ED Policies and Their Relationship to the Care of Older ED Patients

What Happens to Older Patients after They Have Been in Your ED

We Need a Geriatric ED Because . . .

Box 2.1 Holy Cross Hospital, Senior Emergency Center

A common impetus for change to a Geriatric ED model is a sentinel event in the ED –

How Might We Create Our Geriatric ED?

And Who Is the “We” Anyway?

Table 2.1 Geriatric ED champions

Geriatric Medicine Champion

What Will Your Geriatric ED Look Like?

Box 2.2 University Hospitals of Leicester ED Frailty Unit