Elderly patients are frequently evaluated in emergency departments. They represent a unique patient population at high risk of medication related adverse events. Pharmacists are in a unique position to assist with many aspects of pharmacotherapy in the elderly. This episode will explore the clinical and operational considerations aw wells as discuss obstacles and opportunities in improving medication-related care of the elderly.
The information presented during the podcast reflects solely the opinions of the presenter. The information and materials are not, and are not intended as, a comprehensive source of drug information on this topic. The contents of the podcast have not been reviewed by ASHP, and should neither be interpreted as the official policies of ASHP, nor an endorsement of any product(s), nor should they be considered as a substitute for the professional judgment of the pharmacist or physician.
(upbeat music) - Welcome to the ASHP official podcast. Your guide to issues related to medication use, public health, and the profession of pharmacy. - Thank you for joining us for the ASHP Pharmacy Leadership Podcast. This series focuses on leadership topics within pharmacy practice, including the business of pharmacy, development of leadership skills, career transitions, and more. For those of you who are CPEL, you can earn re-certification credit for listening to this episode. Listen after the episode to learn how. My name is Brittany Tashain, and I will be your host today. Today, we're sitting down with the pharmacy team at UC CSF to discuss their geriatrics program in the emergency department. Welcome and thank you for joining us today. I'm looking forward to talking to both of you today. To start us off, are both of you able to introduce yourself to the audience? - My name is Claire Bainbridge, and I am a clinical pharmacist at UCSF, currently practicing in our age-friendly emergency department. - Hi there, thanks for having us. My name is Alan Korolek, and I'm an emergency medicine clinical pharmacist at UCSF. I've been there for the past 16 years and worked very closely with Dr. Bainbridge in establishing the geriatric program at UCSF. - Thank you both. I'm very much looking forward to hearing about your program at the emergency department at UCSF. So can I start it? Can you let us know a little bit about what is an age-friendly emergency department, which I think is also known as AFED? - Yeah, that's a great question. So AFED or age-friendly emergency department. Now, it doesn't necessarily represent a physical space per se, but it's really more about tailoring our care, using this interdisciplinary team that we work with with an expertise in geriatrics and overall just providing high quality care to this vulnerable patient population. You also may hear the term geriatric ED. So that's synonymous with AFED. And we just find that the term age-friendly really tends to be a little bit more well received from our patients as opposed to geriatric, but they're essentially the same thing. - Just to point out the emergency department sees all walks of life from neonatal patients to kids, to adults and geriatric patients. All the emergency departments across the states have been becoming busier and busier, and it's not a very friendly environment for all the early patients, which have some unique needs compared to the usual patients in the emergency department. And it's a natural progression to want to focus on the geriatric patients just because some of the things that happen in the ED can potentially result in harm, especially when it comes to medication, which we'll talk about quite a bit. - Great, thanks for sharing that with the audience. Can you tell us a little bit more about the pharmacist role in this clinical services that is really geared towards working with the geriatric patient? - Yeah, so as emergency pharmacists, clinical pharmacists in the emergency department focus on all patients. However, we do have limited time to focus very important aspects of care for all patients. For example, reviewing in detail, everybody's medication list would be impossible without somebody who can focus on those issues and be a dedicated resource. Different departments have tried different things. Some folks utilize medication reconciliation technicians that are very helpful. However, that is just one part of the equation. The other one is scrutinizing those medications, especially in the elderly, that place them at high risk for an adverse drug event. And this is where we've found a very unique need for having a pharmacist who's dedicated for reviewing medications for the elderly patients and making their recommendations. And this is where Dr. Bainbridge comes in. - Yeah, I definitely agree with what Dr. Corillic has said so far. As you can imagine, it's a very chaotic environment for the older adults. We see that this unique patient population has a number of medications often experiencing polypharmacy. They have altered pharmacokinetics and pharmacodynamics for which prescribing these medications can often be challenging, decreasing renal function over time as we age requiring medication dose adjustments. So really serving as that medication expert and identifying polypharmacy in inappropriate dosing, medications that are potentially inappropriate for this patient population are all kind of some of the areas and rules in which the age-friendly pharmacist serves in our emergency department. - Thank you both. It sounds like the geriatric population is a really unique population, especially in the ED where they're just coming to care and really not as much as known about them at the time. So it sounds like pharmacy can really have a great impact on them at that time. Can you tell us a little bit about how you got this clinical service started? Was like kind of like how you guys got it off-running and kind of any changes that you've seen over time. - From an emergency medicine perspective, there's resources and national movements that are focused on the unique aspects of care of elderly patients in the emergency department. So in collaboration with our emergency department, physicians, we saw an opportunity to get together in a multi-disciplinary fashion. So not just physicians and pharmacists, but physicians, pharmacists, nurses, social work, everybody that's involved in care of any patient in ED or especially the elderly patient to come together to apply for a grant which was subsequently received and that gave us the initial spark to start working on this on the service. And just to point out that the age-friendly emergency department or the geriatric emergency department is not a different physical space within a department. It's still within the regular four walls or however many walls the emergency department has, but it's a state of mind when it comes to care of these patients, which is having clinicians really focused and sensitive to issues that affect the elderly patients. But back to the original question, that's how we initially started was by months long planning, discussing with other emergency departments that have started this program and then designing a specific role for a pharmacist to fill that role just because we knew that the emergency medicine pharmacists could not dedicate full attention to the clinical service for all the ED patients and then also for the elderly patients as well. - Yeah, in addition to all of the things that Dr. Croal mentioned, kind of some of the boots on the ground type thing when starting any new service that people may be unfamiliar with is obviously advertising and kind of making sure that the ED providers are all well aware of this new clinical service that is offered and available to them. For us, this looked like ensuring to announce our presence at our morning and afternoon huddles, making sure that we were readily accessible, educating our providers with what we can help with and essentially just finding our niche. Obviously as the pharmacist, as we kind of mentioned before, we're serving as that medication expert. So really leveraging that expertise in terms of how we're able to help our various ED providers. We do have available, you know, there are geriatric emergency department guidelines that exists that kind of can help, you know, with initiating any sort of age-friendly emergency department service, as well as ASAP or the American College of Emergency Physicians actually offers an accreditation standards, a tiered service. So making sure that we're adhering to these standards that are listed in our national guidelines as well have all been part of how we have worked towards building our clinical service, our age-friendly emergency department. - Thank you both for sharing. It sounds like you had a very comprehensive approach to really building this service and really helping patient care. Were there any barriers or challenges that you didn't really foresee that occurred throughout and how were you guys able to adjust and modify your approach based on this? - So yeah, there are definitely a number of barriers and challenges kind of establishing this role as well as just inherent in this patient population. As you can imagine, our older adults often have atypical presentations of kind of our standard ED diagnoses, for example, they may not present with an ACS event that is with that typical crushing chest pain and things like that as compared to our younger patients. So I think that's one, just challenge with continuing to familiarize yourself with these atypical presentations that older adults may present with and kind of differentiating them from our younger patients. I think obviously there's limited hours in the day prioritizing our patients. We see many, many older adults in our ED specifically. So triaging and prioritizing the patients. Consistent with all of our patients in the EDs, we oftentimes have missing or incomplete information that we're trying to base our information off of. So I think that's like another challenge. These patients specifically also may not be able to contribute to some of their signs and symptoms. They may have cognitive disorders but also may limit our workup and limit their ability to communicate with us as to whether or not they're in pain, what's really going on. Time constraints obviously are always a big barrier as well. So I think these are some of the challenges and barriers that we've experienced so far in our age-friendly emergency department. - Thank you. I think really identifying these specific needs earlier on in a patient's day is very helpful for their long-term stay in their overall hospital stay in transition to care. In particular, are there any specific common clinical conundrums experienced by age-friendly patients in the ED that you guys have really helped to navigate? - There's definitely many clinical conundrums that our older adults experience. I mentioned earlier the atypical presentations that older adults may experience. So just diagnosing the patient and figuring out what's going on with them is oftentimes a challenge. One clinical conundrum that comes up frequently is anticoagulations. Should we anticoagulate this patient that has AFib with an elevated chance mask who's also a high fall risk? And there's oftentimes a debate about whether or not we should proceed with anticoagulation or not despite some of the evidence suggesting the amount of time you'd have to fall for the anticoagulant risks to outweigh the potential benefits. Another clinical conundrum that often comes up is patients that come in confused or delirious and may end up getting a hearing culture and find that they're growing some bacteria and whether or not we should be treating this asymptomatic bacteria. So I think this is also sometimes a hard one for us to manage as delirium is not a symptom of urinary tract infections. And this obviously really has low specificity and evidence is really mixed. And according to our guidelines, we shouldn't be starting antibiotics for asymptomatic bacteria, but it's challenging in these patients that may not be able to communicate if they have symptoms. And so this is just another area, clinical conundrum that comes up with our older adult patient populations. But this is just a few of many, many conundrums. - And just to kind of, through example, to be as straightforward as possible, I mean, elderly patients, generally speaking, take more drugs, polypharmacy is a big issue. They may have different prescribers, they prescribe different medication, different time periods. So one of the things that happened, just to give you an example where I, as a clinical pharmacist who's then processing all the admission orders for an elderly patient, where I really see the value of what Claire and her team are doing, Dr. Bainbridge and her team are doing, is a common scenario a patient comes in, they may have four or five different blood pressure medications on their profile. And for many good things that electronic health records are helpful with, one of the things that the providers can do is just click reorder on each one of those medications. So you may have a patient that has been off of anti-hepertensives for maybe four months, a year, two years that just got reordered. And this is really where the emergency, the geriatric emergency department of pharmacist kicks in. When I process those medications and knowing that Dr. Bainbridge has scrutinized that medication list, that they've talked to the patient, that they figure out what they have been taking, what's their current medication list, what actually is happening at home at the point of admission, makes my job so much easier. And I have so much more confidence that those medications that we process for admission are gonna be safe because it's so easy to reorder those medications that are historical on the patient list that may have been there for years. And it just doesn't happen with blood pressure medications, it happens with antibiotics and even with anticoagulants sometimes, we know that the other patients that are at high risk for adverse drug events from all medications, especially the high risk medications. So having Dr. Bainbridge and her team speak with these patients, focus on their medication needs, focus on what's actually happening at the time that they're admitted to the hospital is of huge, huge, huge help. And I have so much more confidence continuing those medications when patients come in than if we were just starting from scratch. - Great, those are very great examples for our audience to really get an idea of really clinically how your interventions and your work can really impact patient care, right? In the emergency room, right when patients present to care. So thank you all for sharing that. So kind of looking forward into the future, what do you see for the service and the landscape of your age-friendly emergency department? - Yes, all projections for the future are that is that there's an increasing aging population. So we're expecting to see more and more elderly patients. We're expecting to see more of them in the emergency departments. So there's a very important need to address these issues that are being started by geriatric emergency department pharmacists. We started this initially as a pilot. This has gone into year two, almost three now. Our subsequent step is to seek additional funding whether from institutional means or elsewhere to continue this clinical service in the foreseeable future. And Dr. Brainbridge is working on many deliverables as far as objective outcomes and things that the geriatric emergency departments do to kind of show the need and the actual effect that the pharmacists can have in this role. So we're expecting more patients and I'm really hoping that we can continue this service for elderly patients that come to the ED. - I definitely agree with Dr. Korolek. As we all know, our older adult patient population is growing exponentially with our aging baby boomers. And these patients already make up a huge portion of our ED visits. And so this is definitely only going to continue to increase, really representing that this unique niche and need is only going to continue to increase. I think we've also seen historically with the first self-identified geriatric emergency department which was established back in 2007, since then the amount of geriatric EDs out there that exists has also continued to increase as of just a couple of years ago. This number of just from just one ED in 2007, every ED to just a few years ago, we now have a couple hundred. And with our ASAP guidelines and accreditation body, I only anticipate that additional EDs will recognize the important need for this service at their institution and will hopefully start to develop these age-friendly emergency departments at their own site as well so that we can continue to serve these patients, these vulnerable patients that really deserve the highest quality of care that we can deliver for them. - Wonderful. Well, I think that's all the time we have today, but I really wanted to say thank you for sharing your experience and journey in building your age-friendly emergency department. As you both mentioned, as the geriatric population is growing and the number of geriatric specified clinical services within the ED like your age-friendly emergency department, I think this will really help other institutions who may want to kind of mimic what you guys have been doing and build a robust program of their own. So thank you again, and to find more member exclusive content, including resources for self-development, leading pharmacy enterprises and teams, practice management, you can find this on the AFHP website. For those looking to earn CPEL certification, please visit elurng.asp.org. Thank you for joining us. And if you enjoyed this episode, be sure to subscribe too at ASHP official podcast. Thank you. - Thank you for listening to ASHP official, the voice of pharmacists advancing healthcare. Be sure to visit ASHP.org/podcast to discover more great episodes, access show notes and download the episode transcript. If you loved the episode and want to hear more, be sure to subscribe, rate or leave a review. Join us next time on ASHP official. (upbeat music) (upbeat music)
