Improving emergency care for older adults

Yale’s Ula Hwang discusses why older patients need particular care in emergency departments and shares her work on improving their care in New Haven and beyond.
Ula Hwang

Ula Hwang

In the United States, adults aged 50 and older make more than 40 million trips to emergency departments (EDs) each year. And that number is expected to grow, says Ula Hwang, professor of emergency medicine at Yale School of Medicine.

Our population as a whole is aging rather than getting younger,” she said. “So if we think we’re seeing a lot of older patients now, it’s only going to double or triple in the coming years.”

Because of this, she says, geriatric emergency care needs to be a priority.

Hwang has spent her career spreading that message and researching how to do this most effectively. Here at Yale, she spearheaded an effort in 2021 to get each of Yale New Haven Health’s emergency facilities accredited as senior-friendly, a standard of care she encourages other emergency departments to pursue.

She sat down with Yale News to talk about why older patients need particular care in emergency departments and what she’s doing to improve their care in New Haven and beyond. This interview has been edited and condensed.

Why do older individuals need special consideration in emergency departments?

Ula Hwang: Older adults are a special population because of physiological, medical, and functional differences. They’re not only older than the average person just like children are not smaller adults. They have different needs, which, for the most part, have to do with physiological changes, meaning changes in how their body functions. It means they’re going to have multiple medical problems and be on multiple medications, which lead to what I would describe as health-related issues. These are effects on the ability to walk, get out of bed, go to the bathroom, or feed yourself. You also have to think about whether patients have dementia or delirium, whether they can take their medications, or if they live alone.

These are things you don’t think about with a 25-year-old, but you’ll think a little bit more about with someone who’s 90. And we have to consider them with every decision we make when it comes to taking care of an older person.

You came to Yale to help Yale New Haven Health [YNHH] emergency departments earn an accreditation that designates them as senior-friendly. Why did you want to do that here?

Hwang: Yale has really amazing expertise in emergency medicine and geriatrics, with some very huge names. But the two weren’t necessarily doing anything together. And I came to Yale with the mindset that this was an opportunity for me to marry the two disciplines and specialties to really improve care for older patients. At my previous institution, it took decades to get this accreditation and we were able to do it here in less than a year. Everyone’s so collaborative here and there was such an openness to doing this. I would say that’s why the process accelerated so quickly. And it’s a big deal because there are only 13 places in the country that are recognized with this status.

How did Yale earn this accreditation?

Hwang: There are three levels that require different standards on staffing, equipment, education, and protocols. We were able to meet the requirements in part because it was a transdisciplinary effort that included not just physicians and nurses but also case managers and the electronic health record programmers and analysts, the whole team.

And secondly, we took full advantage of the electronic health record. What’s nice about Yale is that if we implement something in the electronic health record of one ED, it gets implemented across the YNHH EDs, and that helped us do this work quickly. We modified some of our protocols — specifically around screening for delirium — and made sure they would work for each of Yale’s facilities.

What have you focused on outside of this accreditation process?

Hwang: My most recent efforts have been around setting up a network of support for geriatric emergency care and research infrastructure. A decade ago, there were no geriatric EDs in the country and now there are over 300 accredited geriatric EDs in the U.S. and some in other countries. So it’s progressively growing. Now we’re trying to evaluate if these EDs are making an impact. Because the more we can demonstrate that they are, the more likely that people in hospitals and emergency departments will start to incorporate this care.

I have some funding now to help set up research infrastructures to highlight where the gaps in care are and where we need more research to improve best practices. We’re also trying to put out pilot funding to support new investigators. We need new people to go into geriatric emergency care. There’s such a demand for research and evidence, but there aren’t enough researchers to build that evidence.

My own research is starting to shift towards dementia. So as our population ages, we’re going to have more and more patients who come in with dementia. We need to optimize the emergency care that people living with dementia receive.

You just published a collection of research papers resulting from a multi-institute collaboration. What did you find?

Hwang: This collaboration is part of that infrastructure-building I’m working on. It’s called GEAR 2.0, which stands for the Geriatric Emergency Care Applied Research Network 2.0. The first phase — 1.0 — focused on geriatric emergency research while this second phase is about advancing dementia emergency care. And it’s not only multi-institutional. We pulled together a task force with over 50 experts from multiple disciplines, including emergency physicians, geriatricians, neurologists, neuropsychologists, nurses, physical therapists, pharmacists, social workers, and people with dementia and their caregivers.

We looked at where our gaps in knowledge were and discussed what the priorities should be going forward. Because my priority as a physician may be very different from what the patient’s or caregiver’s priorities are.

What would you want to share with other emergency departments or physicians?

Hwang: That you don’t need to have a ton of money to address the special care needs of older patients. It’s just a matter of taking a look at the resources you already have and pivoting them. We didn’t get any new resources or money to attain this accreditation here at Yale. It was a matter of getting the existing teams to shift their focus and coming up with protocols that in the end actually make things easier for the emergency department staff.

Lastly, geriatric emergency care is an area that is ripe for growth. And doing this work can really be a lot of fun. To age well is a goal we all have, and I think even in the emergency department, we have the ability to help get patients there.

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