Why Focus on Geriatric Emergency

1
Why Focus on Geriatric Emergency?

• Demographics - baby boom generation is aging,
  requiring care
• Elderly are a unique sub-set of our population

2
Why Focus on Geriatric Emergency?

• Myths about the elderly in Emergency
• elderly misuse the ED - not
  urgent/emergent
• dont see family MD
• Utilization and age related differences
  in the ED

3
Why Focus on Geriatric Emergency?

• Our hospital population aging
• EDs important role in health care

4
Why Focus on Geriatric Emergency?

• Consequences of inaccurate assessments
  and treatments in the ED
• Consequences of inappropriate
  (avoidable) hospital admissions

5
Hospital Dangers to Elderly

• Pressure sores
• Loss of function
• Infections
• Confusion,
  Disorientation
• Falls

6
Why Focus on Geriatric Emergency?

• Consequences of inappropriate discharges
• Cuts in health care and CCAC funding/
  
• health care restructuring
• ED revisits

7
Barriers to Providing Geriatric Care in the ED

• Lack of ED staff geriatric training
• - medicine and nursing skills
• Fee - for- service - funding mechanism -
  assessing, treating elderly takes longer, is
  not compensated

8
Barriers to Providing Geriatric Care in the ED

• EDs philosophy vs. Geriatrics philosophy
• Lack of ED geriatric support staff
• - expanded ED roles
• - geriatric nurse specialists
• Ageism/lack of interest in geriatrics

9
Barriers to Providing Geriatric Care in the ED

• Lack of community supports
• Poor communication between ED, LTC
• Primary care - GP shortages
• Hospital administrations attitudes and
  understanding of the problems

10
Who are the High - Risk Elderly?

• patients in advanced age - gt 75yrs
• - falls
• - cognitive changes (acute
  confusion, dementia NYD)
• - decreased mobility with acute
  limitation
• - at risk of requiring long term care

11
Who are the High - Risk Elderly?

• Sunnybrook GEM not currently using screening
  tool
• New information system in ED GEM nurses can
  look up any ED patient
• Close collaboration with Social Work in ED

12
Sunnybrook and Womens Experience

• 1986 first attempt to institute Geriatric
  Emergency Management (GEM)
• 1994 - GEM take two
• change in health care environment
• 40 of ED visits were gt65 yrs.
• 13/14,600 referrals to specialized geriatrics

13
Sunnybrook and Womens Experience

• Discussed with all stakeholders,
• heard their concerns
• EDs greatest fear that program would
  increase ED LOS
• May - 1995 site visit to Montreal

14
Sunnybrook and Womens Experience

• October 1995 - March 1996 piloted the Role
  of an ED Geriatric Nurse Clinician
• Funding available only for pilot .
• Received 185 referrals in six months
• (from emergency medicine, nursing staff,
  social worker and self-referred)

15
Sunnybrook and Womens Experience

• Emergency Department, previously sceptical about
  GEM, became biggest supporter, helped persuade
  hospital administration, once pilot funding over
• Chief of ED strongest advocate for GEM permanent
  funding

16
Sunnybrook and Womens Experience

• Most common clinical problems
• 1) falls
• 2) cognitive changes (acute confusion,
  dementia, acute confusion NYD and dementia
  NYD)
• 3) decreased mobility
• 4) failure to thrive

17
Sunnybrook and Womens Experience

• Reasons to refer to Geriatric Nurse
  Clinician
• - Geriatric assessment to facilitate safe
  sustainable discharge home
• - Assist ED staff with admission decision
• - Co-ordinate appropriate follow-up plans
  for the at-risk geriatric patients

18
Sunnybrook and Womens Experience

• We learned that geriatric support in the
  ED
• decreases hospital admissions
• coordinates discharges with
  improvement in relapse interval
• (ED revisits)

19
Sunnybrook and Womens Experience

• facilitates identification of high-risk pt.
• facilitates the appropriate follow-up care
• establishes process improvement with mandatory
  geriatric consults for high- risk elderly
  starting in the ED

20
Sunnybrook and Womens Experience

• identifies ED practices which could contribute to
  elderly patient decline, increase hospital LOS,
  and potentially cause irreparable damage
• identifies ED staff Geriatric educational needs
  through a needs assessment survey

21
Sunnybrook and Womens Experience Today

• Geriatric Nurse Clinician 1.0 FTE , 7 days
• 60 referrals/month on average
• Establishing a GEM data base
• - patient profile
• - flow of patient

22
Sunnybrook and Womens Experience Today

• ED staff geriatric education needs
• Plan outcome evaluation using Program
• Logic Model advocate for more GEMs
• Weekends piloted in 2000
• Program is now 7 days

23
Sunnybrook and Womens Experience Today

• Current Challenges
• Hospital deficit
• CCAC cutbacks
• RN Staff in flux in ED agency RNs
• Role clarification needed,
• viz a viz Social Work

24
Sunnybrook and Womens Experience Today

• Current GEM Objectives
• Carry out ongoing evaluation
• Broader Geriatric Education, ED Staff
• Better integration between GEM, SGS
• eg., protected clinic slots for ED
  referrals

25
RGP TORONTO GEM TASK FORCE

• Representatives from RGP Toronto Network
  hospitals
• Project Manager hired
• Meeting May 14, 2002

26
RGP TORONTO GEM TASK FORCE

• Working with our network hospitals to add value
  to geriatric emergency management
• Different tools suit different hospitals
• - diverse patient populations
• - organizational cultures, values
• - when cant add staff, can still add
  skills, knowledge protocols, guidelines

27
RGP TORONTO GEM TASK FORCE

• High-Risk Screening Tools
• Protocols
• GEM Networking, sharing information about
  initiatives, innovations set up email
  listserve
• Elder-friendly ED Environment develop
  audit tool