~
219
Geriatric EM Curriculum, Witzke, Sanders
The Development and Evaluation of a Geriatric
Emergency Medicine Curriculum
Donald B. Witzke, PhD, Arthur B. Sanders, MD, f o r the SAEM Geriatric Emergency Medicine Task
Force *
I
ABSTRACT
. , . . _............
...
_ . . . . . . . . . . , _ . . . . ,. . . . . . . . . . . . . . . . . . .
.............................
......................................
Objective: To summarize the processes used to develop a curriculum and model of care for the emergency
medical treatment of elder patients and to assess the efficacy of the teaching material in a pilot course.
Methods: A survey of emergency medicine (EM) residency directors and geriatric fellowship directors was
used to identify key topics for inclusion in the didactic material. An interdisciplinary consensus process was
used to develop didactic as well as teaching material in geriatric EM. Pretests and posttests were administered
to 46 participants in the initial course to assess knowledge gain. Subjective course evaluations were also done.
Results: Test scores significantly increased from 54% correct on the pretest to 77% correct on the posttest (p
c 0.001). Significant improvement in knowledge as judged by pretest and posttest results occurred in 6 of the
7 teaching modules. Subjective evaluations demonstrated good to excellent ratings for each module as well
as the overall workshop.
Conclusions: The process of developing a curriculum for geriatric EM is described. The initial training of
instructors was effective in improving participants' knowledge of geriatric issues in EM. Participants considered the training to be effective. The effect of the training on the emergency care of elder persons remains
to be determined.
Key words: geriatric; emergency medicine; curriculum; education.
Acad. Emerg. Med. 1997; 4:219-222.
I In 1990, SAEM created an interdisciplinary Geriatric
Emergency Medicine Task Force through funding by the
John A. Hartford Foundation of New York to study the
emergency care of elder persons in the United States. This
task force concluded that principles of care for elder emergency patients have not been defined and that there was
a dearth of education in geriatric emergency medicine.' In
1993, a project to develop a new model and principles of
emergency care for the elder patient and a geriatric emergency medicine (EM) curriculum was implemented.
This report focuses on the 3 phases in the development
of the didactic and teaching material:
From the University of Kentucky, College of Medicine, Lexington, KZ
Department of Pathology and Laboratory Medicine and Student Testing
and Evaluation, Office of Academic Affairs (DBW); and the University
of Arizona, College of Medicine, Tucson, AZ, Section of Emergency
Medicine, Department of Surgery (ABS).
Douglas K. Miller; MD, St. Louis University? St. Louis, MO; John E.
Morley, ME, BCh, St. Louis University, St. Louis, MO; Lidia Pousada,
MD, New Rochelle Hospital Medical Center; New Rochelle, NY; David
B. Reuben,' MD, University of California, Los Angeles, L o s Angeles,
CA; Kathleen M. Richmond, RN, BS, Sisters of St. Casimir Injnnary,
Chicago, IL;Sharon Sheahan, PhD, CFNP, University of Kentucky, Lexington, K E and Robert H. Woolard, M D , Brown Universiry, Providence,
RI.
*The following members of the Geriatric Emergency Medicine Task
Force of SAEM assisred in the development of the materials in this
project: Edward Bernstein. MD. Boston University. Boston, MA; Rawden Evans, PhD, MD, Universiry of Michigan, Ann Arbor; MI; Glenn
Freas, MD, JD, Temple University, Philadelphia, PA; Darrin Fryer, MD,
Kern Medical Center; Bakersfield, CA; David M. Habben, AS, Paramedic, Consultant. Boise, ID; Richard s. Hartoch. MD, Portland Velerans Affairs Medical Center; Portland, OR; Gordon A. Ireland,
P h a d , Sr. Louis University, St. Louis, MO; Jefiey S. Jones, MD,
Michigan State University, Grand Rapids, MI; Norm KalbJeisch, MD.
Portland Veterans Affairs Medical Center; Portland, OR; Pamela Kidd,
RN, PhD, CEN, University of Kentucky? Lexington. KY; Mark Lachs.
MD, MPH, Cornell University, New York, NY; Joseph LaMantia, MD,
The Albert Einstein College of Medicine, Bronx, Nu; Robert M. McNamara, MD, The Medical College of Pennsylvania, Philadelphia, PA;
1. a needs assessment of what topic areas should be included in the curriculum;
Received: March 20, 1996; revision received: June 19, 1996; accepted:
June 26, 1996; updated: September I , 1996. This was a project of
SAEM sponsored in p a n by the John A. Hartford Foundation of New
York Materials described in this article, including textbook, teaching
manual, transparencies, and videotapes, are available through SAEM,
901 North Washington Avenue, Lansing, MI 48906-5137; telephone
51 7-485-5484.
Address f o r correspondence and reprints: Donald B. Witzke, PhD, Department of Pathology and Laboratory Medicine, University of Kentucky College of Medicine, MN-I03 Chandler Medical Cenrer; Lexington, KY 40536-0084. Fax: 606-323-2076; e-mail: dbwitzl @pop.uky.edu
220
I
ACADEMIC EMERGENCY MEDICINE
TABLE 1 Geriatric Emergency Medicine Topic Organization
.............................................................................
I. The Elder Person’s Special Needs in Emergency Medicine
a) Demographics and Emergency Care
b) Physiology of Aging
c) Pharmacology and Aging
d) Ethical Issues
e) Attitudes and Ageism
11. Geriatric Emergency Care Model
a)
b)
c)
d)
Principles of Care
ED Environment
Out-of-hospital Care
ED Geriatric History and Physical Examination
e) ED Disposition Planning
f) Roles of Health Care Professionals
g) Nursing Home Transfer Process
111. Instruments for ED Assessment
a) Mental Status-Delirium
b) Functional Assessment
c) Case Finding
IV. Specific Clinical Issues
a) Altered Mental Status
b) Functional Decline
c) Trauma and Falls
d) Abuse and Neglect
e) Acute Myocardial Infarction
f ) Acute Abdominal Pain
g) Infections
h) Cerebrovascular Accident
i) Dizziness
2. the development of a problem-based curriculum to
teach the didactic material; and
3. the evaluation of the success in teaching the curric~lum.*-~
Members of the Geriatric Emergency Medicine Education Panel participating in this developmental process
included practitioners from EM, geriatrics, nursing, pharmacology, medical education, and emergency medical
technicians.
I .....................
METHODS
Study Design: A cumculum needs assessment was performed by surveying EM educators, emergency nurses,
geriatricians, and emergency medical services (EMS) personnel. A problem-based curriculum was designed by
members of these health care personnel groups and evaluated among practicing emergency physicians (EPs) who
registered for a continuing education course based on the
curriculum.
Needs Assessment: The first step employed in this initiative was establishing a set of objectives for the development of the training. This effort consisted of generating
a list of topics that were relevant to the emergency health
MAR 1997 VOL 4 / N O 3
care of the elder person that might form the basis of a
geriatric EM
A survey of 58 alphabetized topics was created by the
education panel members and sent to directors of all E M
residency programs in the United States, directors of geriatric fellowship training programs, and convenience samples of emergency nurses and paramedic educators. The
survey queried whether each topic was included in the
traininghraining materials, whether the topics were essential, and whether they were appropriate in the curriculum
(the items are available from the authors).
Of the 120 professionals who returned the survey, 50%
were EPs, 21% geriatricians, 22% nurses, 2% EMS professionals, 3% EPIgeriatricians, 1% nurseEMS professional, and 1% other. Forty topics were rated as essential
by at least 30% of the respondents.
The results of the survey were discussed by members
of the education panel and a final set of topics to be included was derived (Table 1). From this material the panel
also developed a set of 11 principles of geriatric EM (Table 2 ) . Thirty-nine topics were used to create the curriculum and subsequently chosen to be included in the accompanying textbook, case-based instructional modules,
or videotapes. These topics were rated as essential or appropriate by at least 87.1% of the respondents. Eleven
topics were not included in the training materials (even
though they received more than 87% of ratings in the
essential and appropriate categories) because discussions
of these topics by task force members indicated that they
were being taught in other venues.
Curriculum Development:
Coals: The training goals established were: 1) to improve the emergency care for elder persons, 2 ) to educate
emergency health care providers about the special needs
of the elder person, and 3) to give emergency health care
professionals the knowledge and tools to feel comfortable
in giving optimal emergency care to the elder patients.
Material Design: Each module (the introduction and
6 cases) contains a specific set of objectives consistent
with the goals, around which all of the learning activities
and materials are based. All modules are linked to the
textbook so that the trainee can read material related to
the case discussions.
In designing the training, it was decided that a casebased interactive small-group (10-20 people) format
would be an effective method of e d u ~ a t i o n . ’ ~ In
- ’ ~the
introduction to the training, an interactive discussion module presents the principles of geriatric EM and the geriatric emergency care model. We also produced and presented 2 videotapes covering attitudes toward elder
persons and the recognition of delirium-2 topics considered difficult to teach by printed material.
The design of the 6 cases revolves around the principles and model of geriatric EM care. Each case begins
with a fall-one of the common emergency presentations
Geriatric EM Cumculum, Wirzke, Sunders
of the elder patient. We suggest that typically, emergency
medical care professionals appropriately manage the
trauma related to the fall, but that it is important to get
beyond the trauma to the reasons for the fall. Each case
discussion session follows a similar format, beginning
with a presentation of the case history. As the case progresses, discussion points are presented to the participants.
At the end of each case, the principles of geriatric emergency medical care related to the case are reviewed, along
with a summary of key learning issues covered in the case.
The instructor has a set of overheads with key teaching
issues related to the case and uses these in the session to
promote discussion and understanding.
Evaluation:
Pilot Test: An 8-hour training session was conducted
at the annual meeting of SAEM in San Antonio in May
1995. Forty-eight EPs participated in the course. Each of
the participants received a draft copy of the textbook. The
training consisted of an introduction to care of the elder
person, and 6 case-based interactive discussion sessions.
Following the introduction, the participants were divided
into 3 groups and rotated through 3 small-group casebased discussion sessions. After a break, the 3 groups rotated through the last 3 case-based discussion sessions. All
the participants reconvened as a large group for a brief
summary of the training, for a question-and-answer period, and to complete a training examination and evaluation. We also asked the participants to provide feedback
to the training faculty about the format and content of the
training.
Course Feedback: Prior to the introduction, a 21-item
multiple-choice examination covering the geriatric EM
health care model and the conditions represented in each
I
TABLE 2 Pnnciples of Geriatric Emergency Medicine*
.....................................................................
1. The patient’s presentation is frequently complex.
2. Common diseases manifest atypically in this age group.
3. The confounding effects of comorbid diseases must be considered.
4. Polypharmacy is common and may be a factor in presentation,
diagnosis, and management.
5. Recognition of the possibility for cognitive impairment is important.
6. Some diagnostic tests may have different normal values.
7. The likelihood of decreased functional reserve must be anticipated.
8. Social support systems may not be adequate, and patients may
need to rely on caregivers.
9. A knowledge of baseline functional status is essential for evaluating new complaints.
10. Health problems must be evaluated for associated psychosocial
adjustment.
11. The ED encounter is an opportunity to assess important conditions in the oatient’s Dersonal life.
*Adapted with permission from: Sanders AB (ed). Emergency Care
of the Elder Person. St. Louis, MO: Beverly Cracom Publications, 1996.
221
I
TABLE 3 Geriatric Emergency Medicine Seminar Examination
Pretest and Posttest Mean Scores (and Standard Deviations) by
Topic
..............................................................................
Topic
Percentage Correct
Significance
Pretest
Posttest
of Re-Post
Mean SD Mean SD
Change
Functional decline
Trauma
Elder abuselalcoholism
Geriatric emergency medicine
health care model
Delirium
Abdominal pain
Ischemic heart disease
53
67
63
49
28
33
34
17
89
84
84
78
16
22
24
14
0.000
0.003
0.000
0.000
56
51
43
22
25
35
77
66
46
26
24
36
0.000
0.005
0.676
TOTALTESTSCORE
54
13
77
11
0.000
of the 6 cases was administered to all participants. At the
end of the training, a posttest, consisting of the same multiple-choice items presented in a different order than the
pretest, was administered. At the conclusion of each module, the participants were asked to complete a brief 3-item
evaluation about each session. To obtain feedback prior
to the final design of the training and training materials,
the participants were asked t o rate the utility and the format of each training module, as well as the overall workshop. The participants also were asked to indicate whether
they would recommend the session or the entire workshop
to others. The participants used a 4-point rating scale to
evaluate each item; 1 = less than adequate, 2 = adequate,
3 = more than adequate, and 4 = outstanding. After the
brief concluding session, the participants were asked to
provide their feedback about each portion of the training
program.
Data Analysis: Internal consistency (reliability) for the
pre- and posttests was determined using Cronbach’s a.
Knowledge gain was determined using the correlated
measures t-test. A p-value of c0.05 was considered significant.
I
RESULTS
...............................................................
Pretest/Posttest: Internal
consistency
reliabilities
(Cronbach’s a)for the pretest and posttest were 0.47 and
0.46, respectively. The percentage of the 46 participants
answering items correctly on the pretest ranged from 7%
to 85%, with the average percentage correct being 54%
(SD = 13%). On the posttest, the percentage of the 43
participants answering the items correctly ranged from
35% to loo%, with the average being 77% (SD = 11%).
This change was significant at p c 0.001 (correlated-measures t-test). Correlated-measures t-tests showed significant improvement in content knowledge in the posttest
compared with the pretest in the overview as well as for
5 of 6 case modules (Table 3).
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ACADEMIC EMERGENCY MEDICINE
MAR 1997
VOL 4/NO 3
Subjective Evaluation: Thirty-five of the 48 participants completed evaluations for the overall training. The
average number of participants completing evaluations for
each of the 7 teaching sessions was 32 and ranged from
14 to 38. The average ratings for the overall training were:
3.7 on a 4.0 scale for “overall utility of workshop”; 3.4
for “overall format of workshop”; and 3.4 for “would
recommend entire workshop to others.”
to which we can generalize the effectiveness of ou; training is limited.
This report is designed primarily to describe the process used to develop the curriculum. This process may be
useful in the development of other special areas in EM.
In the future, it would be useful to track the use of this
material in EM training and assess its effect on the treatment of the elder person.
I DISCUSSION
I CONCLUSION
Previous studies have shown a need for training emergency health care professionals in the care of the elder
Our solution to this problem was the development of training materials and a workshop that individuals involved with teaching emergency health care professionals could use in their institutions. In this regard, we
were careful to construct a workshop that could be used
by a variety of professionals in a wide variety of sessions
and formats. This concern for an interdisciplinary approach to the problem of emergency health care of the
elder population is highlighted by the backgrounds of the
professionals represented on the education panel.
The process of determining topics relevant to geriatric
EM resulted in a number of important medical conditions’
being eliminated from our training materials. The limitations and restrictions imposed by the design of our training and the goals of the project made many of these decisions difficult. However, through many telephone
conferences of the education panel, decisions about eliminating or including any topic were made on the basis of
consensus agreement. The final list of topics we included
in our training and training materials reflects issues that
we believe are not adequately covered in most current
training programs about the elder person.
The decision to use a case-based discussion format for
the presentation of a geriatric EM curriculum was not
made lightly. A thorough discussion of the format was
conducted among panel members. Both the personal experience of the members and the evidence from the casebased instruction literature supporting the effectiveness of
such an approach for adult learners influenced the decision
for the cased-based format.
The process of developing a curriculum for geriatric EM
is described. Consensus was used to develop principles of
geriatric EM and to choose specific topics for didactics.
The initial training of instructors was effective in improving the participants’ knowledge of geriatric issues in EM.
The participants considered the training to be effective.
The effect of the training on the emergency care of elder
persons remains to be determined.
I LIMITATIONS AND FUTURE OUESTIONS
.. . .......
As discussed previously, our data are limited by the small
numbers of trainees and questions posed. It is possible
that our item sample of 21 questions was insufficient to
adequately measure change or that the use of the same
test items on both the pretest and the posttest may reflect
only a focused learning of the content of these test items.
Also, the low reliability on both the pretest and the posttest considerably limits the reliability of the change score,
and may indicate that the basis for the change is a random
effect. If any of these conditions is true, then the degree
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3. Sanders AB (ed). Instructor’s Manual: Emergency Care of the Elder
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