Geriatrics in the Emergency Department :

OROR

ED, Geriatricshave very different

Priorities

Diagnostic Processes

Thinking

Personnel

Blind MenFeelingan Elephant...

EDWhat is your chief diagnosis here

today ?

Is it life-threatening ?

How efficiently, quickly can we move you through the ED, and on out to wherever you are going ?

Geriatrics

What is your current level of functioning, and how can we maintain it, prevent your losing function ?

What are all your co-morbidities ?

How do your various treatments

interact ?

Who/what are your support systems ?

What else do you require for support?

BUT

But ...

You are the

samepatient/family, with the same problems

ED, GERIATRICS SPEAK DIFFERENT LANGUAGES

Translation is required ...

Enter ...

GEM

GEM

12 Toronto hospitals Hamilton, Ottawa, Kingston RGP British Columbia, Quebec Cleveland, Ohio

etc., etc.

GEM in GTA

SunnybrookScarborough Grace, GeneralNorth York GeneralToronto East GeneralSt. Joseph’s Health CentreUHN [TWH and TGH]York Central, Markham StouffvilleSt. Michael’sHRRH [Church St.]

GEM Service Models

Diverse models

Particular to each hospital’s needs ,

resources

Diverse GEM service models

Resource RNAdvanced Practice NurseNurse-ClinicianCNSScreening toolsCross-appointed staff

Sunnybrook pioneered GEM

Hospital committed to LTC [veterans] busy ED - 14,500 > 65 yrs

Pilot project, 6 months 1995-6 185 referred [vs. 13 / previous one year] GEM permanent, 5 days/week June 1996 7 days/week since 2002

GEM nurses funded by RGP and Sunnybrook

Role Models

Montreal site visits

Jewish GeneralRoyal VictoriaMontreal General

Fear

Sunnybrook ED biggest fear, introducing GEM: Increased LOS in ED

Reasons for referral

History of fallsCognitive changesPossible abuse / neglectSubstance abuseCaregiver stressCaregiver hospitalized … /2

Reasons for referral (2)

Functional declineAnxietyAcute / Chronic PainRepeated ED visits /

hospitalizationsPlacement

Referral Sources

Emergency MDs, RNs VolunteersCasefinding [computer EDIS]CommunityConsultantsAfter-Hours Referral BoxVoicemail

Geriatric Nurse- Clinician Role

AssessmentsHelp decide to admit or notCo-ordinate followupGeriatric ResearchEducation

GEM stats

Patients seen, 2002 682

Average per month 56.8 [Range 48 – 73]

Facilitated Discharges 70 %

GEM Bedside Assessment

Observation Cognitive AssessmentChart ReviewTelephone Inquiries, Professional FollowupHome Support

GEM Assessment Tools

Folstein Mini-Mental StateGeriatric Depression Scale [short form]Confusion Assessment MethodRGP Assessment Form [same

for day hospital, clinic, consult team]

Social Work screening tool

GEM Links to Community Resources

CCACsGPs, ConsultantsSGS servicesDay CareLifelineVolunteer DriversPlacement

GEM Education

Staff Inservices Orientation of new staff

Informal Education [for staff, caregivers,

patients]

Marketing of services, media

GEM on Hospital Committees

‘Crisis Visits to the ED’ group Community PartnershipGeneral Medicine Pain Collaborative ProjectQuarterly Meeting: all GEM nurse-

clinicians and all ED social workersAccreditation, Quality ImprovementED Renovation

Challenges: Clinical

Pain ManagementIsolated Seniors / Limited

FinancesCrisis PlacementAbsence of Convalescent Care

Challenges: Triage

Bias Reporting :

‘Failure to Cope’‘Social Admission’‘Placement’

Challenges: Admin.

MarketingVacation ReliefEvening CoverageRotation with Consult Team

Keys to Success

Visibility Office LocationPrevious Clinical ExperienceHands-On CareTimely Followup“Practical Tips for Seniors Visiting ED” … /2

Keys to Success (2)

FlexibilityMarketing / OrientationCollaboration with Key PlayersLinking to Community ResourcesPartnershipsFeedback / ED Evaluation Forms … /3

Keys to Success (3)

ClothingTransportationLoaner EquipmentLifeline VouchersPamphlets / Handouts

RGP Toronto Network

24 participating GTA hospitals

Provincial funding

other Ontario RGPs

Toronto RGP activities

LeadershipAdvocacyServiceEducationResearch

Toronto RGP - Core Services provided by members

Outreach teamsAmbulatory care clinicsInternal consultation teamsGeriatric Rehabilitation UnitsAcute Geriatric UnitsDay HospitalsGeriatric Emergency

Management

RGP GEM Task Force

To spread the word, share knowledgeProject Manager hired February, 2002

Members: 12 hospitals, ED & Geriatrics Quarterly meetingsSubcommittees ad hoc re screening

tools, elder-friendly environment, etc.

GEM Task Force Five Initial Priorities

High risk screening toolNeeds AssessmentGeriatrics Education for

Professionals

Elder-friendly EDPolicy Paper

Consultations to Hospitals

For hospitals seeking to improve geriatric emergency management

What is possible even if you cannot hire a specialized geriatric nurse for the ED

“Toolkit”

Workshop outline

Observation Guide, for elder-friendly ED

High-risk screening tool

Needs assessment, data analysis support

Electronic listserves

Ideas for Future GEM

‘geri area’ in ED

Strategic partnerships between LTC, acute care hospitals [examples]

Research : EMS workers gather information

Other suggestions ?

RGP Website

www.rgp.toronto.on.ca

Contact

Lisa Newman, MSW MHScProject ManagerRGP GEM Task Force

(416) 480-6100 #7334

lisa.newman.a@utoronto.ca

Contact

Catherine Bald, RN BScNNurse-Clinician

RGP GICT / GEM(416) 480-6100 #3194,

pager #1213

Catherine.Bald @sw.ca