Introduction

More older people are coming to the Emergency Department and this poses organisational challenges with longer waiting times and more physicians involved. However, we primarily notice a lack of knowledge and expertise to adequately treat older people in the ED, which leads to poor patient outcomes, such as mortality and functional decline [1,2,3,4]. Whereas medicine in general and Emergency Medicine in particular is disease-oriented and highly protocolized, older people in the Emergency Department (ED) often present with frailty syndromes or atypical complaints that may make protocol-driven approaches unsuitable. Although knowledge on frailty syndromes is increasing, it remains a challenge to translate this knowledge reliably into daily clinical care [5,6,7].

The European Task Force for Geriatric Emergency Medicine is a collaboration of the European Society for Emergency Medicine (EUSEM) and the European Geriatric Medicine Society (EuGMS). The Task Force has the aim to develop clinically sustainable and cost-effective, patient-centered health care systems that improve relevant outcomes for older patients in Emergency Medicine [8], upholding the principles of evidence-based medicine. Previously, a European Curriculum was composed based on which various courses have been organized to increase knowledge and experience of health care workers in Geriatric Emergency Medicine [9]. However, other parallel approaches are needed to increase impact on everyday clinical care for older ED patients throughout Europe. Developing and disseminating pragmatic guidance for Geriatric Emergency Medicine professionals, based on the latest knowledge and expert recommendations, may further help to increase knowledge and competencies of professionals and hence improve outcomes of acutely ill older patients, attempting to bridge the ‘know-do gap’ [10].

The aim of the present manuscript was to develop expert clinical recommendations based on expert consensus, by the review of recent guidelines and literature, on a prioritized list of topics relevant to Geriatric Emergency Medicine throughout Europe.

Methods

A three-step approach was used to develop expert clinical recommendations. We chose not to perform a series of formal systematic reviews as we anticipated they are (a) likely to deliver low-level evidence only (as recently reviewed by Preston et al. [11]), (b) with the rapid knowledge expansion likely outdated on the day of publication and (c) very time-consuming. For these reasons, we decided to make “expert clinical recommendations on Geriatric Emergency Medicine”: based expert consensus and including their knowledge and review (albeit not systematic) of existing literature.

First, a modified Delphi technique was used to prioritize the most relevant topics during a face-to-face meeting in Aartselaar (Belgium) in June 2019. The expert group consisted of geriatricians, emergency physicians, nurses and researchers from eight countries, mostly in Europe. These experts were invited through the Special Interest Group on Geriatric Emergency Medicine of EuGMS and the section on Geriatric Emergency Medicine of EUSEM. Membership of this group was drawn from across all of Europe (list countries) and during our discussion, specific attention was paid to avoid country-specific solutions or recommendations. In addition to the topic prioritization, the meeting in Aartselaar also determined the structure and development process of the final recommendations. Second, a series of recommendations for each of the eight topics was elaborated based on literature review and expert consensus. Following the meeting, eight separate working groups worked on the content of the recommendations. Each group consisted of at least a professional with experience in Emergency Medicine and one in Geriatrics. Finally, the content of all recommendations combined were discussed in the expert group, to establish consistency, relevancy and applicability in clinical practice.

Selection of topics

A comprehensive list of topics was generated in a general discussion based on key documents in Geriatric Emergency Medicine [i.e., (1) the prioritized Research Questions (to be published), (2) the McCusker List [12], (3) the Silver Book [13], resulting in a 'long list of topics']. Next, a three-round modified Delphi procedure was used to reach consensus on the most relevant topics for which expert clinical recommendations would be written. In the first round, all attendants were asked to prioritize their top eight questions from the full list. Topics which were not included following compilation of the priority lists were eliminated. In the second round, members of the panel discussed the topics on the list and got the opportunity to justify their responses. In the second voting round, attendees received instructions to score the topics of the abbreviated list. A weighted voting system was used with each individual awarding marks to a topic based on their priority ranking. Topics were scored and tallied. A third round of discussion ensued afterwards, upon which a consensus was reached and the top prioritized topics were selected.

Form of recommendations

The expert clinical recommendations were developed in the form of posters with similar lay-out and structure across prioritized topics. The goal was to create posters that are easy to consult in the fast-paced environment of the ED, with concise and clear clinical pragmatic recommendations.

For each topic, the poster structure contained three sections addressing the following points (following the Golden Circle principle of Simon Sinek [14]):

  • Why is this an important topic? e.g.: is this disease very prevalent? Is it under-recognized? Does it have a significant impact on outcomes?)

  • How can we improve this situation? (For instance: does better recognition lead to better outcomes? Are there interventions that are effective to improve outcomes?)

  • What can you do practically, in the form of a “Toolbox”? (For instance: what assessment tool is best to detect high risk? What intervention can you start doing in the ED now?)

All posters contain links to more elaborate overview of literature and recommendations, relevant references and the toolbox using QR-codes.

Content of expert clinical recommendations

For each topic, working groups were convened who:

  • Reviewed the available evidence and sought relevant existing guidelines/reviews/landmark studies, using a PubMed search; relevant evidence was selected by the experts based on relevance for the topic.

  • Formulated recommendations by the expert group, based on the literature and expert knowledge.

  • Engaged relevant expertise to inform the guidance from other specialist societies, for example, the European Delirium Association and from patient groups.

The proposed content was then presented to the expert group for discussion and to reach consensus on the following:

  • The content and detail of the background information provided.

  • The formulation of recommendations and voting on the final recommendations. For each recommendation, consensus was sought and found, sometimes after amendment of the recommendation.

  • Signposting to specific tools.

The first versions of the posters were developed in the English language and with generic recommendations regarding specific instruments to use. The task force creating the posters was endorsed by the boards of both EUSEM and EuGMS. It is the explicit intention to translate the posters to other countries, both in language and in choice of relevant instruments. National endorsement will be sought from national organizations.

All posters will be available as PDFs and web-pages free of charge through https://posters.geriemeurope.eu/.

Results

The full list of topics contained 21 possible topics and is shown in Appendix 1. After the second round of discussion, eight topics were selected to be included in the first expert clinical recommendations and are shown in Table 1.

Table 1 Topics for Geriatric Emergency Medicine guidelines selected by experts after modified Delphi procedure
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The process started in May 2019 and final votes on the content of the recommendations were held during an online meeting in June 2021. Over a 2-year period, two face-to-face meetings and seven online expert group meetings were held. More face to-face-meetings were planned, but cancelled due to the COVID-19 pandemic. Individual working groups for the separate topics worked in parallel.

The recommendations made by the experts on each topic can be found in Table 2.

Table 2 Geriatric Emergency Medicine guidelines—recommendations per topic
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An example of the content of the posters is shown in Fig. 1.

Fig. 1
figure 1

Poster expert clinical recommendations on topic 2: age/frailty adjusted risk stratification. Example of a poster that can be used to educate caregivers in the ED on age and frailty adjusted risk stratification

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Recommendations for education and implementation of the Geriatric Emergency Medicine expert clinical recommendations can be found in Appendix 2 and 3.

Discussion

This paper describes the process and outcomes of the Geriatric Emergency Medicine clinical expert group. Recommendations have been made on eight key topics. The materials to implement these recommendations into practice are provided in the appendix.

The field of Geriatric Emergency Medicine has been expanding in the last two decades. Geriatric Emergency Medicine guidelines have been developed in the USA [15]. Also, several sets of quality indicators have been published in the USA [16, 17], UK [18] and Germany [19], as well as text books that have been written on this topic [20, 21]. Furthermore, specific guidelines and reviews on typical geriatric syndromes and problems for the ED have emerged [22,23,24]. Our initiative is a first attempt to translate the increasing knowledge in Geriatric Emergency Medicine into guidance for professionals working in Europe. The existing lack of such translation—referred to as the ‘know-do gap [10]”—hampers timely implementation of this knowledge. Because of the aim to deliver very short guidelines for clinical practice on one hand, and the expected low quantity and evidence-level of the literature [11, 25,26,27], we did not perform formal systematic reviews and no systematic evidence-grading, but rather used expert experience and consensus. The unmet urgent need to increase awareness, knowledge and competencies of professionals working in Geriatric Emergency Medicine validates such a pragmatic approach, but does not at all exclude that future research should further increase evidence-level and recommendations. The expert clinical recommendations will therefore be updated regularly. Our pragmatic approach allowed us to deliver rapid guidance—although postponed by the COVID-19 pandemic—with recommendations that may have an impact on patient outcomes throughout Europe in the short term. Our recommendations are based on expert consensus and not systematic reviews. In response to the limited empirical evidence in this area, we have recently publishes a research agenda that will hopefully stimulate more research in this field [28].

Dissemination across Europe

In Europe, a large diversity in healthcare systems, available resources and existing care protocols do not allow for recommendations that are both general to all patients and specific to each healthcare setting. For instance, the presence of a strong General Practice network (which is not the case in every single country) may influence ED patient population and epidemiology as well as recommendations on post-acute care. However, with the involvement of professionals from countries across Europe we have made these expert clinical recommendations as tailored to the European situation as possible. The posters were primarily generated in English and made available to the European community of Geriatric Emergency Medicine, with the explicit intention to make them available open-access and free of charge. An example of other guidelines disseminated in this fashion are the European Resuscitation Council Guidelines [29]. In collaboration with the authors, individuals may translate the material and make changes to better suit the local national context. The posters are added in the Appendix.

Implementation and education

Recent literature indicates that ED professionals are often not well trained in geriatrics and geriatric educational programs effectively improve their knowledge and evidence-based standards of older patients care in ED [30]. Appendix 2 gives recommendations on how to implement education on Geriatric Emergency Medicine in the ED. It shows how to choose topics to be covered and discusses several different teaching options such as simulation training, microteaching and learning events. Simultaneous to educating ED staff, structural efforts need to be made to implement the clinical recommendations on Geriatric Emergency Medicine into everyday practice. Appendix 3 shows how to plan your approach and gives links to further resources. It gives advice on a multi-level and multidisciplinary approach as well as how to use data to drive change and possible barriers which can be encountered during implementation.

Strengths and limitations

One of the strengths of these expert recommendations is the use of the modified Delphi procedure, through which clinicians working in this field were able to provide input on the most important topics for which recommendations needed to be developed. The multidisciplinary and trans-European collaboration is also a strength, with emergency physicians, geriatricians and nurses working together. The visually attractive posters that were developed, as well as an overview of the possible tools that can be applied to aid clinical decision-making, will support the education of healthcare professionals involved in the care of older people in the Emergency Department, which has to potential to improve the care for older patients throughout Europe. Using QR-codes further information can be found, which can add to the further dissemination of knowledge.

A limitation is that we did not perform a full literature review of these topics applying a GRADE procedure. Instead we used expert opinion to create expert clinical recommendations that can help closing the know-do gap. Furthermore, this is not an extensive initiative on all possible topics relevant to Geriatric Emergency Medicine. Finally, the expert group only consisted of physicians and nurses and did not include (for instance) healthcare directors or patients. We are planning however to expand the range of topics in the future and believe we covered the most important ones for this first phase.

Conclusion

Using a multidisciplinary and pan-European approach, we developed expert clinical guidelines for Geriatric Emergency Medicine. These recommendations come in visually attractive posters and advice for implementation and education, aiming to close the ‘know-do’ gap. Future efforts will be made to further expand these on relevant topics.