Clin-STAR Journey Story

The Emergency Department: Adapting Patient Care and Research for the COVID Crisis

In Providence, RI, where Elizabeth Goldberg, MD, ScM, FACEP, practices geriatric emergency medicine, COVID-19 hospitalizations peaked in late April 2020. While many of her colleagues in other specialties were able to pivot to consulting from home, "When you're an emergency physician, there is not the opportunity to opt out," she says.

Dr. Goldberg has appointments at both Rhode Island Hospital—the only Level 1 trauma center in the state—and Miriam Hospital, a community hospital. Both are teaching affiliates of Brown University, where Dr. Goldberg is associate professor of Emergency Medicine, and Health Services, Policy and Practice. She completed her internship and residency at Brown, where she also did a post-doctoral research fellowship at the Center of Gerontology and Healthcare Research, and earned a master's degree in epidemiology.

"On the one hand, you feel more vulnerable in the emergency department," she says. "On the other hand, because we were seeing these patients with this new illness, it allowed us to be at the forefront of making observations, and to report on trends."

In addition, because of her experience with geriatric medicine, Dr. Goldberg's colleagues turned to her for advice and training on how to talk about end-of-life care during the COVID crisis. "I've never heard this much discussion about frailty, and end-of-life and palliative care among my colleagues as I'm hearing now," she says. "I think that has changed, and it's really important."

Before the pandemic, Dr. Goldberg spent much of her emergency department (ED) shifts leading teams of medical students and residents as they cared for patients. Dr. Goldberg also works closely with students from Brown's MPH and biotechnology programs, who were poised to contribute to her research program as they completed their theses and other requirements. Goldberg’s team members saw an opportunity to restructure a paper that was in progress before the pandemic. This resulted in a publication in April, with MSTAR scholar Swechya Banskota as first author, on smartphone apps to help older adults cope with isolation.

Dr. Goldberg's broader research interests lie at the intersection of aging and emergency medicine. In 2019, she received a Paul B. Beeson Emerging Leaders Career Development Award in Aging, for a project to evaluate the use of wearable devices. Specifically, Dr. Goldberg is evaluating the use of the Apple Watch to track motor and cognitive activities in older adults recovering from falls that brought them into the ED. This research extends Dr. Goldberg's earlier R03 Grants for Early Medical/Surgical Specialists' Transition to Aging Research (GEMSSTAR) award.

Wearable devices allow researchers to collect data remotely, so it might seem that a study built around such devices would be ideal for a time when participants are sheltering at home. But restrictions on in-person interactions have still posed challenges.

"I'm really troubled by how long it's taken me and my colleagues around the country to restart their research programs," says Dr. Goldberg. Efforts to contain community spread, like limitations on going into the workplace and restrictions about how to approach older persons have dramatically changed how they can do research—and slowed the pace.

For her Beeson research, Dr. Goldberg had started in-person recruitment in the ED. This came to a halt when the pandemic hit. She also discovered that older adults need hands-on help with learning and trouble-shooting the technology she is evaluating. Before the pandemic her team would go to study participants' homes to help them, but now they must rely on caregivers being able to assist.

"It's going to be a very different study from what we started out doing. We've completely restructured the protocol so that we just call patients that came to the ED the day before, and do everything from a distance using video and phone calls."

In general, Dr. Goldberg has seen an increase in short-term funding opportunities from both NIH and foundations to support researchers during this transition. In fact, Dr. Goldberg was granted a supplement to her Beeson Award to support doing more work at a distance and adjusting the protocol for recruitment.

In the longer term, Dr. Goldberg believes COVID-19 has opened new avenues for research. For example, "I think we're going to see an increase in discussions about digital tools, and what's called ambient assisted living—monitoring health at home to enable older people to be cared for at home rather than in a hospital," says Dr. Goldberg. "We will also be looking at creative ways to do rehabilitation as we move forward."

"There's a lot of opportunity right now for people who have cross-training in geriatrics and emergency medicine. We know that other physicians may not give as much hands-on care as we do, so it's important to do what we can to make care appropriate and ideal for older people."