Louis Stokes Cleveland VAMC
PITTSBURGH — A standardized tool designed for intermediate care technicians and nurses to screen high-risk older veterans in emergency departments for injury, illness and unmet needs effectively detects cases of elder abuse, according to a new study.
The study published in Academic Emergency Medicine examined the value of the Elder Mistreatment Screening and Response Tool (EM-SART), which was piloted in the Louis Stokes Cleveland VAMC’s Geriatric Emergency Department program.1
The tool was administered to older veterans who were seen at that VAMC location and screened into the geriatrics emergency department program based on their risk factors. Patient data was obtained from electronic health records.
“Elder mistreatment is common, but it can often go undetected in healthcare settings,” Lena K. Makaroun, MD, MS, core investigator at the Center for Health Equity Research and Promotion at the VA Pittsburgh Healthcare System, told U.S. Medicine. “Visits to a doctor may be an ideal time to initiate interventions for mistreatment. This is true across all healthcare systems, not just in VA. Our prior research showed wide variability in screening practices. Front-line clinicians see an unmet need and want a reliable tool to use.”
It’s estimated that 1 in 10 older adults experience mistreatment every year in the United States. The veteran population may be at particularly high risk for mistreatment, given a high concentration of risk factors in this population, Makaroun explained in an email.
VHA emergency department visits provide a unique opportunity to identify elder abuse, because assessment for acute injury or illness may be the only time isolated older veterans leave their homes. However, most VHA emergency departments don’t have standardized elder abuse protocols.
To address this, the researchers assembled an interdisciplinary team of VHA social workers, physicians, nurses, intermediate care technicians (former military medics and corpsmen who often conduct screenings in VHA emergency departments) and both VHA and non-VHA elder abuse subject-matter experts to adapt the EM-SART to pilot in the Louis Stokes VAMC program.
The interdisciplinary geriatric emergency department consultation was led by intermediate care technicians and nurses who screened high-risk older veterans for geriatric syndromes and unmet needs. The adapted EM-SART was integrated into the electronic health record and geriatric emergency department workflow in December 2020. By July 2022, 251 veterans were screened, with nine (3.6%) positive on the prescreen and five (2%) positive on the comprehensive screen.
While the research team wasn’t directly involved in the initial development of the EM-SART, they suggested that the VA was an ideal place to test this important tool.
“We found that the tool was helpful in detecting elder mistreatment cases directly,” Makaroun explained in an email. “In addition, implementing the tool was a valuable process to educate clinicians and staff about the signs and symptoms of elder mistreatment. The staff’s awareness increased during this pilot, and they were better poised to spot informal signs for concern.”
“We did find that the tool, which had been developed outside VA, needed to be adapted to meet the specific needs of veterans and the unique resources and processes present in VHA emergency departments. This was an important lesson—that the EM-SART tool is flexible enough to be adapted to the unique setting where it is being used, which makes it much more useful given how different emergency departments across the country may have different resources, staffing, etc.”
The study’s results build on existing trials of the EM-SART tool by examining its use in VA, the largest integrated health system in the country. The ability to adapt and widely disseminate this tool in VA could have big implications for the field of elder mistreatment detection and response more broadly, Makaroun wrote in an email.
Makaroun recommends the EM-SART tool to healthcare professionals and systems who are interested in developing a tool for elder abuse detection. Because there are no national guidelines on elder mistreatment screening, the researchers have seen a lot of variability.
“With newer elder mistreatment screening tools being developed and increasingly studied, we recommend that health systems choose a studied tool, adapt it as needed, educate their staff and track data on its use,” Makaroun wrote. “This last point is very important, because elder mistreatment detection is still a new area, and we need to be taking every opportunity to learn about what’s working and what’s not working and disseminate this to the field.”
For the future, the researchers are working on updating the VA electronic health records with the adapted version of the EM-SART tool. Then, they will pilot this version at a larger number of sites. The results from this next pilot will be used to determine whether any further adaptations might be needed before ultimately making this tool available in VA nationally.
“Our goals are twofold,” Makaroun explained. “We want to increase elder mistreatment detection directly by giving clinicians a helpful, reliable tool. At the same time, we are also enhancing clinicians’ capacity. By increasing VA staff’s ability to spot the signs of elder mistreatment, we are also laying the groundwork for them taking the next steps in managing this serious and often undetected problem.”
VA has long been a leader in research and innovative clinical programs to address complex geriatric syndromes. Improving how VA detects and responds to elder mistreatment in VA emergency departments is another way for VA to be at the forefront of meeting the needs of aging veterans, Makaroun added.
“Elder mistreatment is a common problem affecting older adults, and emergency department (ED) visits are a unique time to identify mistreatment concerns and initiate interventions to reduce harm and improve outcomes,” Makaroun wrote. “Using a standardized and evidence-based tool adapted to the local needs of each ED can help train staff and improve elder mistreatment detection in a time-efficient way that is feasible in busy EDs. EDs that are interested in achieving Geriatric ED Accreditation (GEDA) can also use standardized elder mistreatment detection practices to meet GEDA criteria.”
- Makaroun LK, Halaszynski JJ, Rosen T, Lees Haggerty K, Blatnik JK, Froberg R, Elman A, Geary CA, Hagy DM, Rodriguez C, McQuown CM. Leveraging VA Geriatric Emergency Department Accreditation to Improve Elder Abuse Detection in Older Veterans using a Standardized Tool. Acad Emerg Med. 2022 Dec 27. doi: 10.1111/acem.14646. Epub ahead of print. PMID: 36575600.