summary emergency departments (eds) are an essential service for the care of injuries and trauma for...
TRANSCRIPT
SUMMARY
Emergency Departments (EDs) are an essential service for the care of injuries and trauma for everyone. They provide a safety net when the system of care is disrupted and services are unavailable. ED care is especially important for seniors who, while approximately 14% of the
population, account for up to 21% of ED encounters. But not all seniors use EDs more than younger people. An increase in ED usage is primarily seen
for seniors whose age (>75 years) places them at increased risk of the complex, bio-psycho-social and functional challenges of frailty. When frail seniors visit emergency departments they have more emergent conditions,
receive more tests, have longer ED stays and are more likely to be admitted into hospital than younger patients . For frail seniors, an ED admission may be a sentinel event. Rates of hospitalization, return ED visits and death in
the months following a visit are higher for frail seniors than for younger age groups
A Geriatric Emergency Management Nursing Network has emerged as an evidence informed best practice to help achieve better health outcomes for
frail seniors in the ED. The GEM network is comprised of 97 advanced practice nurses in 60 EDs in 13 Local Health Integration Networks (LHINs) across the province. At its recent 9th Annual GEM conference, the network members worked with a team of facilitators from Health Quality Ontario to explore core GEM processes in three areas: How do patients get to GEM,
what happens when they get there and what happens afterwards. To inform this quality exploration an online GEM practice survey was completed by
61% of presently active GEM nurses from 10 LHINs.
The present poster presents background on GEM together with some preliminary results from the GEM Practice Survey and process maps in the
three areas of GEM practice.
The GEM nursing network was initiated by the Regional Geriatric Programs (RGPs) of Ontario and is coordinated by the RGP of Toronto.
For additional information please contact:
Kerri Fisher, CoordinatorRegional Geriatric Program of Toronto Email: kerri.fishersunnybrook.caTelephone: 416.480.5881
UNIQUE VULNERABILITIES OF FRAIL SENIORS
Symptom presentation is complex and atypical Multiple co-occurring illness Poly-pharmacy is the rule not the exception Diagnostic tests may have normal value Functional/compensatory reserves are limited Psychosocial circumstances are changing Support systems are stretched Risk of hospitalization is high Capacity for independent living is threatened
Determine level of risk Assess and clarify elements of frailty Identify geriatric syndromes Clarify atypical presentations Guide appropriate resource utilization Inform care coordinators and health
system planners Communicate concerns to other
stakeholders (geriatric services, family physician, community services, long-term care home)
Identification of seniors at risk in the Emergency Department (ED) Timely, targeted, essential and accurate assessments Identification of geriatric syndromes Screening of functional ability Optimize linkage with community supports Appropriate referral and disposition Reduced admission and re-visits to ED and/or hospital Prevent delirium and functional decline during the ED visit Enhanced patient safety Build geriatric capacity throughout the ED Adapt GEM practices to best meet local needs and services
GOALS OF GEM PROGRAM
FACTS ABOUT GEM
References:
• Meldon SW, Mion LC, Palmer RM et al. A brief risk-stratification tool to predict repeat ED visits and hospitalizations in older patients discharged from the emergency department. Acad Emerg Med. 2003;10(3):224-32
• RGPs of Ontario GEM Progress Report 04-05
www.rgps.on.ca
• Central East LHIN GEM Program
Poster was developed by Dr. David Ryan from the resources of the Regional Geriatric Program of Toronto and the Ontario GEM Nurse Network
A Network of
60 Hospitals in 13 LHINS across Ontario
Triage nurse assesses
Nurse does CTAS assignment Clerk registers Clerk sends to
waiting room
Nurse calls to assign bed
- acute- subacute
- see and treat- fast track
Nurse does secondary
assessmentED doc assessesEMS gives report PT, CCAC, SW
assesses
Begins with: Senior arrives at the
hospital
Patient has first contact with GEM
nurse
10% referred to GEM nurse right
away
50% referred to GEM nurse
20% referrals to GEM nurse generated
GEM nurse case finding
CCAC, Primary Care, Aging at Home, Intensive Geriatric
Social Worker call from community in advance that
patient is coming in
GEM Nurse gathers information
- Meditech for visit- History- GAIN visits- Doctor- EMS- Primary ED RN- Family- Interprofessional team- LTC Staff- NLOT team- CCAC- ODP
Establish rapport
- Get patient story- Generate questions
Conduct appropriate assessments
- Screening- Delirium- Care Supports- Medications- Living Situation- Falls- Social assessment- Skin Assessment- Nutrition- Frailty scale- ADLs, IADLs- Safety- Hydration
Physical exam
Patient and family concerns
Assess available resources to
mobilize
Assess potential to go home
Assess medical and social needs
Discharge or admit?
Arrange consults as needed
- PT, OT, SLP, Geriatrics, BSO,
CCAC, Transportation
Communicate- in hospital- external
Call GP Follow up after doscharge
Decide to transition
How do patients get to us?
What do we do once we have them?
THE GEM PROCESS MODELING
ASSISTED BY HQO
RANK ORDERING OF THE PRESENTING
PROBLEMS OF PATIENTS SEEN BY GEM
BETTER HEALTH OUTCOMES : SERVICE, ADVOCACY, RESEARCH AND EDUCATION
ED Assessment and Treatment complete
GEM ensure home is a safe place
GEM nurse and internal health team
review results
GEM nurse and team communicate
with family
GEM nurse and team collaborate
with team members
Family and caregiver support
Is patient ready to go home?
Everyone makes decision – patient,
team, family
Direct admit (hospital policy)
Doctor discharge
(hospital policy)
GEM nurse coordinate referrals
- CCAC- Community
pharmacy- Family doctor
Community resources
GEM nurse coordinates/does
paperwork
GEM nurse creates a summary report
for patient and sends to referral
and patient
GEM nurse follows up with referrals
GEM nurse determines how patient will get
home
GEM nurse coordinates
- Home at Last- Medication
- Transportation- Settling in service
How do we make transitions happen?
SERVICES AVAILABLE AT GEM HOSPITALS
USAGE RATES FOR EIGHT GERIATRIC ASSESSMENT TOOLS
Distributed matrix program management model Collaborative program rollout Team development, training and mentorship Linkage with the Nurse Led Outreach Teams and GAIN Clinics
in various LHINS Implementation of a common basic GEM model Empowerment of adaptations to meet local needs Routine risk screening Targeted assessment Capacity Building within EDs, hospitals, CCACs, Community
Service Agencies and Long-Term Care Routine outcome and user satisfaction evaluations
BENEFITS OF ASSESSMENT
SATISFACTION SURVEY RESULTS OF GEM SERVICES
Item 8
29.5%25%
11%6.7% 6.6%
75%
15%10%
0
10
20
30
40
50
60
70
80
Screen and Refer Comprehensive GEM Assessment
Targeted Geriatric
Assessment
Consultations to other ED staff
Follow-up assessments for
discharged patients not seen
by GEM
Clinical Service GEM Capacity Building
Admin Duties