summary emergency departments (eds) are an essential service for the care of injuries and trauma for...

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