Redefining Emergency Care: Stanford’s Trailblazing Approach to Geriatric Health

It’s no secret that our nation is getting older. The demographic shift, often called the ‘silver tsunami,’ means emergency departments across the U.S. are increasingly becoming the frontline for complex, age-related care needs. You see it every day, don’t you? Patients arriving with a tangled web of chronic conditions, polypharmacy issues, and often, an underlying frailty that traditional ED environments simply aren’t equipped to handle effectively.

Think about it for a moment. The typical ED, with its relentless pace, the cacophony of alarms, the fluorescent glare, and those seemingly endless waits on hard gurneys—it’s a high-stress environment. For older adults, these conditions don’t just feel uncomfortable; they can actively worsen health outcomes. Long wait times can lead to dehydration or medication delays. Lack of mobility support often precipitates falls. The constant noise and disorientation can trigger or exacerbate delirium. It’s a challenging picture, and frankly, one we haven’t always addressed head-on.

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Enter Stanford’s pioneering initiative. What they’re doing there isn’t just incremental improvement; it’s a systemic reimagining of geriatric emergency care. Their approach is built on a simple yet profoundly powerful premise: small, deliberate structural changes, when applied consistently across an entire department, can dramatically improve patient safety, reduce complications, and, perhaps most importantly, create a more humane and dignifying care experience for our older population.

Embedding Excellence: A Holistic View of Geriatric Care

Now, you might expect a facility like Stanford, with its considerable resources, to simply build a dedicated geriatric ED unit. Many institutions do, and there’s certainly merit in that model. But Stanford took a different path, one that I personally find incredibly insightful and arguably more impactful. Rather than segregating older patients into a separate unit, they chose to embed geriatric principles throughout their entire emergency department. This ensures that every older patient, regardless of their presenting complaint or the specific bay they land in, receives age-friendly care.

This isn’t just about ticking boxes on a compliance checklist; it’s about designing resilient systems. It means the critical interventions and considerations for older adults aren’t dependent on whether a specific geriatric specialist is on duty or if the attending physician has extra time. The system itself is designed to work, to flag, to guide, and to support, even when the department is bustling, and everyone’s stretched thin. It’s a proactive, integrated approach that really puts the patient first.

Key Innovations: Beyond the Basics

The changes Stanford implemented are comprehensive and touch nearly every facet of ED operations. Let’s delve into some of these crucial innovations and understand their true impact.

First up, and vitally important, is their overhauled delirium screening tools. Delirium, often mistaken for dementia in the chaotic ED setting, is a common and serious acute brain failure in older adults. It’s associated with longer hospital stays, increased mortality, and permanent cognitive decline. Traditional screening methods frequently miss it, partly due to time constraints and a lack of standardized, easy-to-use instruments. Stanford developed improved tools, integrated into their workflow, that significantly boost diagnostic accuracy and completion rates. Imagine the relief of catching delirium early, initiating appropriate interventions, and potentially preventing weeks or months of confusion and functional decline for a patient and their family. It’s profound.

Then there’s the focus on minimizing unnecessary fasting (NPO) times. For many older patients, prolonged periods without food or drink—often required for imaging scans or potential procedures—can be detrimental. It can lead to dehydration, electrolyte imbalances, and even accelerate frailty, especially if they’re already vulnerable. Stanford established new, collaborative protocols with their radiology and anesthesia departments. This means a more thoughtful, individualized approach to NPO, ensuring patients are fasted only when absolutely necessary and for the shortest possible duration, mitigating those preventable complications.

A particularly impactful policy involves catheter use reduction. Urinary catheters, while sometimes necessary, carry significant risks, especially for older adults, primarily catheter-associated urinary tract infections (CAUTIs). These infections can lead to sepsis, prolonged hospital stays, and increased mortality. Stanford implemented a strict policy, tying catheter insertion and continuation to meticulous physician and nurse documentation. It forces a pause, a consideration: ‘Is this catheter truly needed, or can we explore other options?’ This simple yet powerful accountability measure has been incredibly effective in reducing unnecessary catheterization and, consequently, infection rates.

Next, consider fall-risk interventions and a custom-built Frailty Screening Tool (GRAED). Falls are a leading cause of injury and death in older adults, often serving as a gateway to further decline. Many EDs address falls after they happen. Stanford’s initiative is proactive. Their GRAED tool, designed specifically for the emergency setting, quickly identifies frailty—a state of increased vulnerability to stressors—and inherent fall risks. Once identified, a bundle of interventions kicks in: bed alarms, non-slip socks, mobility assessments, early physical therapy consultations, and even simple things like ensuring call bells are within reach. It’s about creating a safe environment from the moment they arrive, recognizing that a seemingly minor stumble can have catastrophic consequences for someone already frail.

And speaking of environment, the physical modifications they’ve made are brilliant in their simplicity. Non-slip flooring isn’t just a nicety; it’s a critical safety feature. Analog clocks help orient patients who might be experiencing cognitive fluctuations or simply find digital displays confusing. Handrails strategically placed throughout the department provide stability and confidence for those with mobility issues. These aren’t flashy, high-tech solutions, but they fundamentally change the sensory experience of the ED, making it less disorienting and more secure for older individuals.

Medication management is another huge win. Older adults often take multiple medications, increasing the risk of adverse drug events (ADEs). Their physiology changes, affecting how they metabolize drugs. Stanford integrated geriatric medication alerts into their Epic EHR system. This means that when a physician orders a medication, the system automatically flags potential issues like drug-drug interactions, doses that need adjusting for age or kidney function, or medications on the ‘Beers List’ (potentially inappropriate for older adults). It’s an intelligent safety net that prevents countless medication errors and side effects.

Effective communication doesn’t stop at discharge. Stanford implemented large-font discharge instructions and automatic PCP notification workflows. Think about trying to read tiny print when your vision isn’t what it used to be, or trying to remember complex instructions when you’re tired and stressed. Large print, clear language—it makes all the difference. And ensuring the patient’s primary care physician is automatically notified of their ED visit and discharge plan? That’s continuity of care in action, bridging the gap between acute and chronic management, and significantly reducing readmission risk.

Human connection also plays a vital role. The age-friendly volunteer program provides much-needed support. These dedicated volunteers engage older patients, offering companionship, helping with orientation, and providing cognitive stimulation. In an environment that can be isolating and frightening, a friendly face and a comforting presence can do wonders for a patient’s emotional well-being and cognitive function, especially for those experiencing early signs of delirium or simply feeling vulnerable.

Finally, the access to palliative care and 24/7 geriatric-trained case managers rounds out this comprehensive approach. Older adults often have complex care needs, encompassing not just physical ailments but also social, emotional, and spiritual dimensions. Palliative care teams can assist with symptom management, goals-of-care discussions, and ensuring treatment aligns with a patient’s wishes. The 24/7 geriatric-trained case managers are invaluable in coordinating post-ED care, arranging home health services, connecting patients with community resources, and navigating the often-labyrinthine healthcare system. They’re the crucial bridge that extends care beyond the ED doors.

The Power of Precision: Data-Driven Transformation

How do you know if all these changes are actually working? That’s where Stanford’s commitment to data-driven decision-making truly shines. A central, indispensable tool in their improvement effort is its real-time geriatric dashboard. This isn’t just some static report; it’s a dynamic, living snapshot of their performance, tracking dozens of key metrics crucial to geriatric care. It’s a testament to the fact that ‘what gets measured gets managed,’ isn’t it?

This dashboard tracks everything from delirium screening rates and catheter usage to boarding times, palliative consults, and fall bundle implementation rates. It also monitors critical outcome measures like readmission and mortality rates. What’s truly impressive is how this data is leveraged. The dashboard supports monthly quality reviews, allowing the team to identify trends, pinpoint areas needing improvement, and implement targeted interventions. It brings a level of transparency and accountability that’s often hard to achieve in busy clinical settings.

For instance, that dashboard was instrumental in helping the team achieve something quite remarkable: zero catheter-associated infections in older adults over the past fiscal year. Think about the impact of that. Zero preventable infections. It also revealed areas where they were excelling, like more than doubling their delirium screening rate, and areas where they needed to refine their approach. It’s a continuous feedback loop that fosters improvement, pushing the department to constantly evolve and optimize its care delivery.

Accreditation: More Than Just a Stamp of Approval

One of the most transferable, and frankly brilliant, insights from Stanford’s experience is the strategic role that accreditation can play. Specifically, they targeted Geriatric Emergency Department Accreditation (GEDA). Now, you might initially see accreditation as just another bureaucratic hurdle, a mountain of paperwork. But Stanford reframed it, viewing it as a powerful strategic roadmap.

By aligning their departmental changes with GEDA standards, they weren’t just aiming for a badge; they were gaining a structured framework for improvement. GEDA provides clear, evidence-based guidelines for what constitutes optimal geriatric emergency care. This framework allowed teams to accelerate projects, giving them a clear target and a set of best practices to follow. It provided the impetus needed to push through complex builds in Epic—those often-challenging EHR customizations that require significant time and resources. And perhaps most importantly, it helped secure crucial cross-departmental support, getting buy-in from various teams, from IT to nursing leadership, because everyone understood they were working towards a recognized, valuable standard.

GEDA isn’t just about meeting minimums; it encourages continuous quality improvement. It pushed Stanford to not only implement new protocols but also to rigorously evaluate their effectiveness. It’s a powerful lever, transforming what could be perceived as an administrative burden into a catalyst for genuine, patient-centered change.

Lessons for Every Institution: Scaling Impact

It’s easy to look at Stanford and think, ‘Well, they have endless resources.’ And yes, their size and funding are unique. However, what’s genuinely exciting is that many of the approaches they’ve pioneered are remarkably scalable and relevant for emergency departments of all types and sizes. You don’t need a multi-million dollar grant to start making a difference. What can we learn?

First, and I can’t stress this enough: use accreditation as a roadmap, not a checklist. Don’t just aim to tick off requirements; use the GEDA standards as a guide to focus on meaningful, impactful improvements for your older patients. It’s about deeply understanding the ‘why’ behind each standard and integrating it into your culture, not just your documentation.

Second, engage interdisciplinary stakeholders early. This means bringing nurses, social workers, case managers, pharmacists, physical therapists, even community members, into the planning process from the get-go. Nurses are on the front lines and often see the earliest signs of decline. Social workers understand the complex discharge needs. Their insights are invaluable, and early involvement fosters buy-in and ensures that solutions are practical and effective across the entire care continuum. You can’t do this alone.

Third, automate workflows in your EHR to ensure follow-through. Let’s be honest, busy clinicians are often overwhelmed. Relying solely on memory or manual processes for complex new protocols is a recipe for inconsistency. Leverage technology. Build those smart alerts, order sets, and documentation prompts directly into your EHR system. This ensures consistency, reduces human error, and makes age-friendly care the default, not an afterthought.

Fourth, and this is crucial for any project: start small. You don’t have to overhaul your entire department overnight. Focus on a few high-impact metrics that are achievable and visible, like improving delirium screening rates or implementing a robust fall prevention bundle. Build momentum with these successes, learn from your experiences, and then expand. Small wins can fuel bigger transformations.

Fifth, build in robust feedback loops using dashboards or monthly committee reviews. Continuous improvement isn’t a one-and-done event. You need mechanisms to regularly assess your progress, identify gaps, and make adjustments. Stanford’s dashboard is a fantastic example, but even a simple monthly committee review of key metrics can be incredibly effective. It keeps the initiative top-of-mind and allows for agile adjustments.

Finally, document and share progress to sustain momentum despite staff turnover. Healthcare is an industry with high turnover. Your champions today might be somewhere else tomorrow. Create institutional knowledge. Document your processes, your successes, and your challenges. Share this progress widely, both internally and externally. This not only maintains buy-in and morale but also provides a clear blueprint for continuity when new staff come on board. It shows everyone that this work isn’t just a fleeting project; it’s a foundational shift.

Beyond the ED Walls: A Vision for Prevention and National Impact

What’s next for Stanford’s team? They’re clearly not resting on their laurels. While much of the current accreditation focus is on care within the emergency department, their vision extends far beyond hospital walls. They’re deeply invested in secondary prevention—ensuring that once a patient is treated for a fall or an episode of delirium, proactive steps are taken to prevent it from happening again. This might involve referrals for home safety assessments, physical therapy, occupational therapy, medication reviews by pharmacists, or even comprehensive geriatric assessments post-discharge. It’s about breaking the cycle of recurrent ED visits and hospitalizations.

They’re also actively working to detect underreported issues, two critical examples being elder abuse and undiagnosed cognitive decline. These are often hidden tragedies, masked by other symptoms or simply missed in the rush of acute care. Training ED staff to recognize subtle signs, implementing discreet screening protocols, and having clear pathways for intervention can be life-saving. Imagine the impact of identifying a vulnerable senior experiencing abuse and connecting them with appropriate protective services, or catching early cognitive decline that can then be managed, potentially improving their quality of life for years.

This isn’t just about Stanford’s ED anymore. The department is now helping to inform broader, hospital-wide age-friendly initiatives, ensuring that the entire institution adopts similar best practices. They’re also preparing for new CMS reporting requirements around older adult care, which will undoubtedly push other hospitals to follow suit. And perhaps most excitingly, they’re considering the development of a multi-site research consortium. This would allow them to collaborate with other EDs nationally, study effective interventions on a larger scale, and truly advance the science of geriatric emergency medicine for everyone.

As Dr. Losak, a driving force behind this initiative, aptly put it, ‘This is a national conversation. We want to collaborate with other EDs, share what we’ve learned, and build a research network that advances care for older adults everywhere.’ It’s about collective impact, sharing knowledge, and elevating the standard of care for an entire generation.

Taking It Personally: A Grandfather’s Legacy

For Dr. Losak, this work isn’t just academic, not just another project. It’s deeply, profoundly personal. Years before he ever donned a white coat, his beloved grandfather, Hank, an individual who deeply influenced his life, died after a preventable fall. That event wasn’t just a personal tragedy; it was a stark, painful revelation of the systemic gaps in care that far too many older adults face.

‘That loss stayed with me,’ he recalled, a quiet intensity in his voice. ‘Now, I have a chance to help fix the national system that failed him.’ It’s a powerful reminder that behind every statistic, every protocol, every data point, there’s a human story. There’s a grandmother, a grandfather, a cherished elder who deserves nothing less than the very best care we can provide. Stanford’s initiative, born from both cutting-edge science and deeply personal conviction, is a beacon of what’s possible when we truly commit to that promise.

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References

• med.stanford.edu/emed/stories/geriatricED.html
• emergencyphysicians.org/press-releases/2025/8-21-25-geriatric-assessment-reduces-hospital-admissions-for-older-adults-study-finds
• emergencyphysicians.org/article/elderly-emergency-care/geda
• hopkinsmedicine.org/news/articles/2025/10/better-emergency-department-care-for-older-patients
• physicianfocus.nyulangone.org/new-multidisciplinary-project-advances-emergency-care-for-older-patients/