Creating a Framework to Triage Geriatric COVID Patients

Provider with geriatric patient

The Centers for Disease Control and Prevention (CDC) reports that 8 out of 10 COVID-19-related deaths in the United States have been in adults 65 years and older. As such, the novel coronavirus pandemic has had a dramatic impact on geriatric care.

Since the outbreak began, geriatrics providers have faced the formidable challenge of optimizing care for a vulnerable patient population while also protecting their own health. Geriatrician Shoshana Streiter, MD, and her colleagues at the Brigham and Women’s Hospital Division of Aging have been on the frontlines since day one.

Dr. Streiter was part of a team that developed a framework to triage older adults with COVID-19 in the emergency department (ED). The collaborative effort included representatives from surgery, palliative care and emergency medicine at the Brigham. An article presenting the framework was published in NEJM Catalyst in November. Lynne O’Mara, MPAS, PA-C, a geriatrics-trained senior physician assistant, was first author.

Lynne O-Mara“In early March, we received multiple requests from clinicians seeking extra support for geriatric COVID-19 patients,” O’Mara said. “We created this framework to provide front-line staff with additional geriatric support during our COVID-19 surge and to target geriatric and palliative care resources to the patients most in need of them.”

“Our goal was to get geriatrics and palliative care assessments early for the patients we thought would need those resources the most,” Dr. Streiter added. “From there, we would 1) make sure we had a good understanding of the patient’s goals for their care in the hospital, and 2) use a geriatrics eye to identify and proactively avert potential problems.”

Taking Timely Action the Key

The framework developed by Dr. Streiter and her colleagues is based on the Clinical Frailty Scale (CFS). This nine-point classification system is used to evaluate a patient’s physiologic reserve and ability to tolerate stress.

The framework called for ED clinicians to identify geriatric patients with COVID-19 upon their arrival in the ED. O’Mara would then conduct a virtual assessment and triage each patient to usual care (CFS 1-3), geriatric co-management (CFS 4-6) or palliative care triage (CFS 7-9).

“We learned that the magic is getting the resources to the patient right away in the ED. Don’t even wait for the patient to be admitted,” Dr. Streiter said. “You make a rapid assessment and recommendations, followed by more formal, comprehensive evaluations after the patient is in the hospital.

“So many times, we saw that the intervention that made a big difference was getting the patient the geriatrics and palliative care support they needed really early in the hospitalization.”

Looking Ahead to an Uncertain Future

With the Boston area facing another surge in COVID cases, Dr. Streiter reflected on all that has transpired since the onset of the pandemic.

As she explained, the Division of Aging is divided into co-management teams, with geriatricians embedded in different services in the hospital, including trauma, orthopaedics and primary care. Dr. Streiter’s team is embedded in internal medicine, where the bulk of COVID-positive patients have been placed. At the peak of the initial surge, mid-April into early May, her entire patient list was COVID-positive.

One of the most difficult aspects of the pandemic, said Dr. Streiter, has been caring for patients with delirium. This is a highly hands-on activity in normal times; she and her colleagues regularly check on these patients to make sure their various needs are being met and to keep them active and engaged. With COVID-positive patients, this level of attention is no longer possible.

“Staff can’t constantly be at the bedside, and I worry about the isolation,” Dr. Streiter said. “Early on, we tried using iPads to help older patients connect with their families, but many of them have cognitive, visual or hearing impairment and couldn’t use the iPads. It was absolutely devastating.”

While Dr. Streiter continues to have serious concerns about her COVID-positive patients being isolated, she is also cautiously optimistic on several fronts. She cited improvements in communicating with patients and families about risk mitigation in the hospital and at home as well as being able to apply the many lessons learned from the past nine months.

“I do feel better the second time around because we know a lot more about COVID and about managing frail, older adults with COVID. I think we’re in a much better position this time,” she concluded. “And the encouraging results from the vaccine studies make it seem like the end may be in sight. That will give people a concrete reason to feel like they won’t have to choose between risking their health and isolating from their loved ones for the indefinite future.”