high-risk elderly in emergency - agenda

1. High-Risk Elderly in Emergency - Agenda Why focus on geriatric care in the Emergency Department (ED)? What are the barriers to providing geriatric care in the Emergency Department?

3. High-Risk Elderly in Emergency - Agenda Recommendations: - what can you do at a local level? - what can we do at a provincial level? Barriers and Recommendations: 1) Reviewed literature 2) examined the emergency program core curriculums, guidelines, educational objectives and accreditation standards (Royal College, Family Practice (U of T) and Nursing -Humber and Centennial) 4) interviewed Dr. Julie Spence - Program Director FRCPC-EM Residency Program 5) Reviewed the Ontario Ministry of Health (1996) report “Review of Hospital and Community-Based Emergency Health Care in Ontario” 6) Reviewed the Ontario Medical Association (1996) report “ Primary Care Reform: A Strategy for Stability” 7) interviewed prominent Canadian Emergency Physicians * DR.. Michael Murray - President of the Canadian Academic Emergency Physicians (CAEP) *DR.. Andy McCallum- Director of Emergency Medicine/Sunnybrook *Dr. Dennis Psutka - Emergency Medicine MD - Chedoke/McMaster 5) explored initiatives undertaken in the United States Society of Academic Emergency Medicine (SAEM)- Geriatric Emergency Medicine Task Force - Geriatric Interest GroupBarriers and Recommendations: 1) Reviewed literature 2) examined the emergency program core curriculums, guidelines, educational objectives and accreditation standards (Royal College, Family Practice (U of T) and Nursing -Humber and Centennial) 4) interviewed Dr. Julie Spence - Program Director FRCPC-EM Residency Program 5) Reviewed the Ontario Ministry of Health (1996) report “Review of Hospital and Community-Based Emergency Health Care in Ontario” 6) Reviewed the Ontario Medical Association (1996) report “ Primary Care Reform: A Strategy for Stability” 7) interviewed prominent Canadian Emergency Physicians * DR.. Michael Murray - President of the Canadian Academic Emergency Physicians (CAEP) *DR.. Andy McCallum- Director of Emergency Medicine/Sunnybrook *Dr. Dennis Psutka - Emergency Medicine MD - Chedoke/McMaster 5) explored initiatives undertaken in the United States Society of Academic Emergency Medicine (SAEM)- Geriatric Emergency Medicine Task Force - Geriatric Interest Group

4. Why Focus on Geriatric Emergency? Demographics - baby boom generation Elderly are a unique sub-set of our population Demographics - Baby boom time frame - later and longer than the U.S. 1947 - 1966 (30% of Canada’s population) - as of 1994 12% of Canada’s population >65yrs. - within 20 years over 30% of Canada’s population >65yrs. - 60 yrs and > HC costs soar - > 80 yrs population is presently the fastest growing segment of the population - NB TREND is arising - (50% lit. states) change in ED patient population with greater proportion of elderly visiting our ED for medical care - and we haven’t seen the worst of it yet - (stats overhead - provincial, North York and Sunnybrook) - irritant to ED workers - prevent them from getting on with what they thought their work was Unique subset - multiple medical conditions - symptoms may be atypical making assessment/treatment more challenging/time consuming - mental energy of ED staff to manage elders care is signif. - process required to obtain history may be substantially more difficult due to cognitive problems (dementia, delirium, confusion d/t hectic ED environment) - sensory loss ( hearing, vision )- communication difficulty - stroke **- require caregiver to interview Demographics - Baby boom time frame - later and longer than the U.S. 1947 - 1966 (30% of Canada’s population) - as of 1994 12% of Canada’s population >65yrs. - within 20 years over 30% of Canada’s population >65yrs. - 60 yrs and > HC costs soar - > 80 yrs population is presently the fastest growing segment of the population - NB TREND is arising - (50% lit. states) change in ED patient population with greater proportion of elderly visiting our ED for medical care - and we haven’t seen the worst of it yet - (stats overhead - provincial, North York and Sunnybrook) - irritant to ED workers - prevent them from getting on with what they thought their work was Unique subset - multiple medical conditions - symptoms may be atypical making assessment/treatment more challenging/time consuming - mental energy of ED staff to manage elders care is signif. - process required to obtain history may be substantially more difficult due to cognitive problems (dementia, delirium, confusion d/t hectic ED environment) - sensory loss ( hearing, vision )- communication difficulty - stroke **- require caregiver to interview

5. Why Focus on Geriatric Emergency? Myths - appropriate use of the ED. - of all age groups the elderly were more likely to be triaged as urgent and had more emergent illnesses than did other age groups - urgent and emergent (lois news paper) - have GP's more often than younger patients - Time of day they visit the ED is most frequently during the day Utilization and Age related differences - more often than younger patients to be admitted to hospital - more likely than younger patients to return to the ED for the same medical problem within two weeks of discharge from the ED - LOS in ED is longer - utilization of resources is greater - although more diagnostic tests were done on the elderly, the younger patient tended to have the more accurate ED dx. *Therefore, the elderly represent a unique sub-set of the emergency population Myths - appropriate use of the ED. - of all age groups the elderly were more likely to be triaged as urgent and had more emergent illnesses than did other age groups - urgent and emergent (lois news paper) - have GP's more often than younger patients - Time of day they visit the ED is most frequently during the day Utilization and Age related differences - more often than younger patients to be admitted to hospital - more likely than younger patients to return to the ED for the same medical problem within two weeks of discharge from the ED - LOS in ED is longer - utilization of resources is greater - although more diagnostic tests were done on the elderly, the younger patient tended to have the more accurate ED dx. *Therefore, the elderly represent a unique sub-set of the emergency population

6. Why Focus on Geriatric Emergency? Important role of the ED in the health care system Consequences of inaccurate assessments and treatments in the ED Consequences of inappropriate (avoidable) hospital admissions Role of ED - large percentage of health care dollars and hospital inpatient days are attributed to the care of the elderly -ED plays a gatekeeping role for acute care - ED is an important decision point in the Health care system for those elderly who come are truly in crisis - an inaccurate decision/diagnosis in the ED results in ramifications for the HC system, providers, consumers and government *Lack of a comprehensive Geriatric Assessment can lead to an inaccurate assessment and misdiagnosis resulting in 1) inappropriate admission or discharge, waste of HC resources, increase recidivism in patients causing possible irreparable damage i.e.. drug ordered in ER resulting in undetected delirium on the unit consequences of an inappropriate (avoidable) admission are many: 1) devastating effects on the health of the elderly patient - (confusion, disorientation, deterioration of physical functioning, incontinence or iatrogenic disease) - caregivers’ reaction to perceived change in patient 2) increase hospital LOS, block beds 3) institutionalizing patients who otherwise would have remained at home with appropriate community supports *therefore increased costs to the HC system Role of ED - large percentage of health care dollars and hospital inpatient days are attributed to the care of the elderly -ED plays a gatekeeping role for acute care - ED is an important decision point in the Health care system for those elderly who come are truly in crisis - an inaccurate decision/diagnosis in the ED results in ramifications for the HC system, providers, consumers and government *Lack of a comprehensive Geriatric Assessment can lead to an inaccurate assessment and misdiagnosis resulting in 1) inappropriate admission or discharge, waste of HC resources, increase recidivism in patients causing possible irreparable damage i.e.. drug ordered in ER resulting in undetected delirium on the unit consequences of an inappropriate (avoidable) admission are many: 1) devastating effects on the health of the elderly patient - (confusion, disorientation, deterioration of physical functioning, incontinence or iatrogenic disease) - caregivers’ reaction to perceived change in patient 2) increase hospital LOS, block beds 3) institutionalizing patients who otherwise would have remained at home with appropriate community supports *therefore increased costs to the HC system

7. Why Focus on Geriatric Emergency? Consequences of inappropriate discharges Cuts in health care funding/ health care restructuring consequences of inappropriate discharge - if discharged home without the appropriate discharge plans and collaboration with the community and primary care system, -elderly patients will functionally decline, - additional burden on the family and community health caregivers, ED revisits in worsened condition therefore increase health care costs. **therefore it is imperative that an accurate assessment /diagnosis and early identification of at risk elderly occur when the patient presents in the ED -must provide the right care, in the right place, at the right time Effects of health care funding cuts on acute care and the Emergency Departments - fewer beds and decreased LOS (3x and your admitted no longer an option) - insufficient community support * major impact on how ED presently manage the care of the elderly consequences of inappropriate discharge - if discharged home without the appropriate discharge plans and collaboration with the community and primary care system, -elderly patients will functionally decline, - additional burden on the family and community health caregivers, ED revisits in worsened condition therefore increase health care costs. **therefore it is imperative that an accurate assessment /diagnosis and early identification of at risk elderly occur when the patient presents in the ED -must provide the right care, in the right place, at the right time Effects of health care funding cuts on acute care and the Emergency Departments - fewer beds and decreased LOS (3x and your admitted no longer an option) - insufficient community support * major impact on how ED presently manage the care of the elderly

8. Barriers to Providing Geriatric Care in the ED Lack of ED staff geriatric training - medicine and nursing fee - for- service - funding mechanism Geriatric Education- The Geriatric Emergency Task Force notes “nearly half or more of the emergency physicians report a higher level of difficulty in managing the clinical presentations of the elderly” - incidents of misdiagnosis despite more diagnostic tests, and revisits to ED with same problem support the idea of lack of training - literature states that ED physicians must add the expertise of a geriatrician to his abilities to deal with the elderly’s complex problems - 1990 SAEM created the Geriatric Emergency Task Force with the objective of disseminating among their trainees the skills of making a comprehensive assessment of the frail ED pt. presenting with a multiplicity of problems - Text book, Education Manual, Core Curricul- -family MD - provide most ED care with no additional ED training- ED -nurses have not been educated to meet the special needs of the older patient - Chris Brymer London - “deficits in nursing practice and knowledge of care of the elderly at a number of community and teaching hospitals Southwestern Ontario. -Fee- for- service - lit. and Michael Murray suggests this payment method rewards doctors who maximize their volumes of pts. seen and penalize those who take time to assess, explain and discuss with pts and caregivers. increase volumes and dx. tests decrease time with pt. Murray - volume indicator does not account for acuity, need for timely access, or outcomes - an alternative funding mechanism must take into account patient needs and the workload associated with those needs. Geriatric Education- The Geriatric Emergency Task Force notes “nearly half or more of the emergency physicians report a higher level of difficulty in managing the clinical presentations of the elderly” - incidents of misdiagnosis despite more diagnostic tests, and revisits to ED with same problem support the idea of lack of training - literature states that ED physicians must add the expertise of a geriatrician to his abilities to deal with the elderly’s complex problems - 1990 SAEM created the Geriatric Emergency Task Force with the objective of disseminating among their trainees the skills of making a comprehensive assessment of the frail ED pt. presenting with a multiplicity of problems - Text book, Education Manual, Core Curricul- -family MD - provide most ED care with no additional ED training- ED -nurses have not been educated to meet the special needs of the older patient - Chris Brymer London - “deficits in nursing practice and knowledge of care of the elderly at a number of community and teaching hospitals Southwestern Ontario. -Fee- for- service - lit. and Michael Murray suggests this payment method rewards doctors who maximize their volumes of pts. seen and penalize those who take time to assess, explain and discuss with pts and caregivers. increase volumes and dx. tests decrease time with pt. Murray - volume indicator does not account for acuity, need for timely access, or outcomes - an alternative funding mechanism must take into account patient needs and the workload associated with those needs.

9. Barriers to Providing Geriatric Care in the ED ED’s philosophy vs. Geriatrics’ philosophy Lack of ED geriatric support staff - expanded ED roles - geriatric nurse specialists Ageism/lack of interest in geriatrics ED Philosophy vs Geriatrics - Dr. Andy McCallum Sunnybrook - ED’s going through a culture change more elderly , chronically ill - becoming more aware of community needs and trying to respond to the needs and the wishes it serves Focus has been one of “Cure” versus geriatrics focus on “health and well-being of an individual” With change in hospital restructuring it created a change in the ED’s need for support staff . The need for Geriatric Support staff increased : Key to sustainable discharge from the ED depends up on: accurate diagnosing problems Negotiating a realistic treatment plan Timely follow-up after discharge establishing responsive on-going supports Ageism/lack of interest in Geriatrics - ED staff do not have a balance experience with the elderly - develop negative stereotype - lit. states that new - to practice physicians have little interest in caring for older or chronic patients ED Philosophy vs Geriatrics - Dr. Andy McCallum Sunnybrook - ED’s going through a culture change more elderly , chronically ill - becoming more aware of community needs and trying to respond to the needs and the wishes it serves Focus has been one of “Cure” versus geriatrics focus on “health and well-being of an individual” With change in hospital restructuring it created a change in the ED’s need for support staff . The need for Geriatric Support staff increased : Key to sustainable discharge from the ED depends up on: accurate diagnosing problems Negotiating a realistic treatment plan Timely follow-up after discharge establishing responsive on-going supports Ageism/lack of interest in Geriatrics - ED staff do not have a balance experience with the elderly - develop negative stereotype - lit. states that new - to practice physicians have little interest in caring for older or chronic patients

10. Barriers to Providing Geriatric Care in the ED lack of community supports primary care Hospital administrations’ attitudes and understanding of the problems community supports -downsizing of hospitals shifted acuity to ED and to the community -greater discomfort in making disposition decisions therefore require Geriatric Support Staff - lit. states in order to ensure the desired patient outcomes, there must be some control and ensurance that appropriate services are delivered after the ED visit primary care Literature notes that some of the elderly’s problems presenting in the ED could be prevented if earlier interventions were taken in the community. Dr. Dennis Psutka - real reason elderly arriving in the ED is due to poor primary care - shortened hours, no house calls , little follow-up to prevent problems -physician reward system (funding mechanism) for volume and high tech services, not the care of the elderly hospital administration -org. must support ED with support workers to address the issues of the elderly in the ED or the problems worsen - systems thinking required, not only focus on the beds, hospital issues, but HC systemcommunity supports -downsizing of hospitals shifted acuity to ED and to the community -greater discomfort in making disposition decisions therefore require Geriatric Support Staff - lit. states in order to ensure the desired patient outcomes, there must be some control and ensurance that appropriate services are delivered after the ED visit primary care Literature notes that some of the elderly’s problems presenting in the ED could be prevented if earlier interventions were taken in the community. Dr. Dennis Psutka - real reason elderly arriving in the ED is due to poor primary care - shortened hours, no house calls , little follow-up to prevent problems -physician reward system (funding mechanism) for volume and high tech services, not the care of the elderly hospital administration -org. must support ED with support workers to address the issues of the elderly in the ED or the problems worsen - systems thinking required, not only focus on the beds, hospital issues, but HC system

11. Who are the High - Risk Elderly? patients in advanced age - > 75yrs - falls - cognitive changes (acute confusion, dementia NYD) - decreased mobility with acute limitation - at risk of requiring long term care - A geriatric consultation is required if yes to one or more of the following four clinical details -comment if patient lives alone - OTHERS that may be considered *Patient with any memory problems -acute, chronic, behavioural * Lives alone * lack of social supports (meals, bathing, shopping, nursing care) *stressed caregiver *?patient abuse * incontinence * multiple medications/ substance abuse * multiple ED visits *sudden change in physical/cognitive status *patient/caregiver in need of health education - A geriatric consultation is required if yes to one or more of the following four clinical details -comment if patient lives alone - OTHERS that may be considered *Patient with any memory problems -acute, chronic, behavioural * Lives alone * lack of social supports (meals, bathing, shopping, nursing care) *stressed caregiver *?patient abuse * incontinence * multiple medications/ substance abuse * multiple ED visits *sudden change in physical/cognitive status *patient/caregiver in need of health education

12. Sunnybrook and Women’s Experience 1986 first attempt to institute Geriatric Emergency Management (GEM) 1994 - GEM take two change in health care environment 40% of ED visits were >65 yrs. 13/14,600 referrals to specialized geriatrics 1986 -outline process - met with ED Medical Director, CNS, managers, EDSW - referral form from ED - only commitment to GEM was from ED SW - when ED SW away , out of sight out of mind of ED staff - even ED SW needed consistent reminding - patient contacted within 24 hours post visit to ED, and still in crisis - home visit required - frail elderly women - 85 >, living alone, few supports 1994 - hospital downsizing, decrease beds and LOS - hot issue - ED management of elderly needed to change - hot issue No beds, lack of community supports 1986 -outline process - met with ED Medical Director, CNS, managers, EDSW - referral form from ED - only commitment to GEM was from ED SW - when ED SW away , out of sight out of mind of ED staff - even ED SW needed consistent reminding - patient contacted within 24 hours post visit to ED, and still in crisis - home visit required - frail elderly women - 85 >, living alone, few supports 1994 - hospital downsizing, decrease beds and LOS - hot issue - ED management of elderly needed to change - hot issue No beds, lack of community supports

13. Sunnybrook and Women’s Experience Discussions held with all stakeholders - 6 month pilot of a Geriatric Nurse Clinician in the ED ED greatest fear - increase ED LOS May - 1995 site visit to Montreal Montreal - 1985 - Quebec Government mandated Geriatric Nurse Clinicians in all ED across 3 hospitals visited - Jewish General, Royal Victoria, and Montreal General Montreal - 1985 - Quebec Government mandated Geriatric Nurse Clinicians in all ED across 3 hospitals visited - Jewish General, Royal Victoria, and Montreal General

14. Sunnybrook and Women’s Experience October 1995 - March 1996 piloted the Role of an ED Geriatric Nurse Clinician Total of 185 referrals in six months (from emergency medicine, nursing staff, social worker and self) Role of ED Geriatric Nurse Clinician Case Finding of high risk elderly provide phone call follow up for d/c patients Geriatric Liaison nurse between: the Emergency and the community the Emergency and acute care Information sharing and consultation with the Emergency Social Worker (must keep roles distinct) - re: disposition of high risk geriatric patients Participation in geriatric research Educate staff, patients, and caregivers re: geriatric services availableRole of ED Geriatric Nurse Clinician Case Finding of high risk elderly provide phone call follow up for d/c patients Geriatric Liaison nurse between: the Emergency and the community the Emergency and acute care Information sharing and consultation with the Emergency Social Worker (must keep roles distinct) - re: disposition of high risk geriatric patients Participation in geriatric research Educate staff, patients, and caregivers re: geriatric services available

15. Sunnybrook and Women’s Experience Most common clinical problem: 1) falls 2) cognitive changes (acute confusion, dementia, acute confusion NYD and dementia NYD) 3) decreased mobility 4) failure to thrive -order of frequency -utilized list to modify high-risk screening list-order of frequency -utilized list to modify high-risk screening list

16. Sunnybrook and Women’s Experience Reason for referral 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 Successful discharge from the ED depends upon: accurate diagnosing problems Negotiating a realistic treatment plan Timely follow-up after discharge establishing responsive on-going supportsSuccessful discharge from the ED depends upon: accurate diagnosing problems Negotiating a realistic treatment plan Timely follow-up after discharge establishing responsive on-going supports

17. Sunnybrook and Women’s Experience What did we learn from the pilot and continue to learn? The geriatric support in the ED: 1) decreased hospital admissions 2) coordinated discharges with improvement in relapse interval (ED revisits) Andy’s letter - take the 127 patients who might otherwise have been admitted to hospital multiply that number by the ALOS for patients with similar OCW’S to get the number of patient days saved Bill Sullivan’s article- “ Evaluating an Emergency Geriatric Consultation Service: Which Interventions Effect Elderly Cognitively Impaired Patients Caught in the Revolving Emergency Door” Primary outcome was the relapse ratio Actual days lapsed from discharge to the next ED visit (or: days lapsed without another ED visit) Average days lapsed between ED visits in the last 2 years (= predicted days to next ED visit) Andy’s letter - take the 127 patients who might otherwise have been admitted to hospital multiply that number by the ALOS for patients with similar OCW’S to get the number of patient days saved Bill Sullivan’s article- “ Evaluating an Emergency Geriatric Consultation Service: Which Interventions Effect Elderly Cognitively Impaired Patients Caught in the Revolving Emergency Door” Primary outcome was the relapse ratio Actual days lapsed from discharge to the next ED visit (or: days lapsed without another ED visit) Average days lapsed between ED visits in the last 2 years (= predicted days to next ED visit)

18. Sunnybrook and Women’s Experience 3) facilitated identification of high-risk pt. 4) facilitated the appropriate follow-up care 5) established process improvement with mandatory geriatric consults for high-risk elderly starting in the ED Identification - helped define high-risk pt. Mandatory Geriatric Consults - -decrease LOS - increase continuity of geriatric care - decrease/prevent patient decline e.g... picked up delirium in ED, pt. to Ortho. Sx. for # hip, Sx. neglected to pick up on delirium if not for Geriatric consult Appropriate follow-up -FP Resident study re: pt./caregiver satisfaction with D/C from GEM with extremely positive results Identification - helped define high-risk pt. Mandatory Geriatric Consults - -decrease LOS - increase continuity of geriatric care - decrease/prevent patient decline e.g... picked up delirium in ED, pt. to Ortho. Sx. for # hip, Sx. neglected to pick up on delirium if not for Geriatric consult Appropriate follow-up -FP Resident study re: pt./caregiver satisfaction with D/C from GEM with extremely positive results

19. Sunnybrook and Women’s Experience 6) identified ED practices which could contribute to elderly patient decline, increased hospital LOS, and potentially irreparable damage 7) identified ED staff Geriatric educational needs through a needs assessment survey Identification of ED Practices - increase hospital LOS - could cause irreparable damage e.g... drug ordered in the ED resulting in delirium on the unit Educational Needs Survey - ED Physician’s difficulty to assess this unique sub-set with atypical presentation was supported by our own educational survey results Surveys used: Results found: Identification of ED Practices - increase hospital LOS - could cause irreparable damage e.g... drug ordered in the ED resulting in delirium on the unit Educational Needs Survey - ED Physician’s difficulty to assess this unique sub-set with atypical presentation was supported by our own educational survey results Surveys used: Results found:

20. Sunnybrook and Women’s Experience Today Geriatric Nurse Clinician 1FTE 28 referrals/month on average Establishing a GEM data base - patient profile - flow of patient

21. Sunnybrook and Women’s Experience Today ED staff geriatric education needs Implementation of outcome evaluation tool using Program Logic Model Weekend pilot January 1st, 2000 - March 31st, 2000 ED Community Advisory Panel - influence re: Geriatric issues ED staff Geriatric Education needs assessment Further Program Planning and Evaluation -implementation of outcome evaluation tool - hiring of new ED Medical Director - monthly meetings ED Community Advisory Panel - influence re: Geriatric issues ED staff Geriatric Education needs assessment Further Program Planning and Evaluation -implementation of outcome evaluation tool - hiring of new ED Medical Director - monthly meetings

22. Others’ experiences/interest North York General Hospital - task force group Regional Geriatric Program Calls from around the province and across the country North York General Hospital -created a Task Force to look at Emergency Services for the Elderly - Taking a CQI approach - with all the right players at the table (ED staff - Chief of ED - ED Unit Manager - Community Liaison Coordinator - Chief of Medicine - Program Director Medicine - Geriatrician- CNS in Geriatrics and Coordinator Geriatric Outreach) Assessing flow of the patient from ED to bed/ or community Identifying data needs - volume, LOS, what causes delay, (imaging, lab etc...) -Make list of recommendations and plan smaller working groups - specific area and ED beds for Geriatrics - Clarification of roles and expectations of Geriatrics - High-risk identification tool/ Explanation of Geriatric support staff to ED/ Education Regional Geriatric Program - interest group, web site, Geriatric ED education workshop, advocate at DHC, Ministry RE: barriers/ issues Province - London - Dr. Chris Breymer - article have copies Hamilton Health Sciences Corporation - ED Gerontological Advanced Practice Nurse / -British Columbia / Newfoundland North York General Hospital -created a Task Force to look at Emergency Services for the Elderly - Taking a CQI approach - with all the right players at the table (ED staff - Chief of ED - ED Unit Manager - Community Liaison Coordinator - Chief of Medicine - Program Director Medicine - Geriatrician- CNS in Geriatrics and Coordinator Geriatric Outreach) Assessing flow of the patient from ED to bed/ or community Identifying data needs - volume, LOS, what causes delay, (imaging, lab etc...) -Make list of recommendations and plan smaller working groups - specific area and ED beds for Geriatrics - Clarification of roles and expectations of Geriatrics - High-risk identification tool/ Explanation of Geriatric support staff to ED/ Education Regional Geriatric Program - interest group, web site, Geriatric ED education workshop, advocate at DHC, Ministry RE: barriers/ issues Province - London - Dr. Chris Breymer - article have copies Hamilton Health Sciences Corporation - ED Gerontological Advanced Practice Nurse / -British Columbia / Newfoundland

23. Recommendations - Local Level Needs assessment of your community, ED, and hospital Monitor needs regularly Identify stakeholders/key people Needs Assessment - do your homework - to assess volume, - assess flow of patient, - revisit rate who’s revisiting - how well geriatric services within the hospital or community (if available) are being used (referral pattern from ED) - what are the pressing issues within the hospital/ED and could Geriatrics play a role * is this an issue in your hospital/community now or in the future - monitor for the shift in demographics Stakeholders -include primary care Needs Assessment - do your homework - to assess volume, - assess flow of patient, - revisit rate who’s revisiting - how well geriatric services within the hospital or community (if available) are being used (referral pattern from ED) - what are the pressing issues within the hospital/ED and could Geriatrics play a role * is this an issue in your hospital/community now or in the future - monitor for the shift in demographics Stakeholders -include primary care

24. Recommendations - Local Level Increase stakeholder’s awareness of the issues/barriers and address their hot issues Ideally get everyone impacted by ED changes involved in the discussion and participating stakeholder’s awareness - No matter what level in the organization you need to make key people/stakeholders aware of the systems issues - to influence - address their hot issues/fears -i.e... Sunnybrook- Decrease LOS, fewer beds, increasing Geriatric population - best way to influence administration address their issues - customer focus approachstakeholder’s awareness - No matter what level in the organization you need to make key people/stakeholders aware of the systems issues - to influence - address their hot issues/fears -i.e... Sunnybrook- Decrease LOS, fewer beds, increasing Geriatric population - best way to influence administration address their issues - customer focus approach

25. Recommendations - Local Be persistent! Look for any opportunity to increase the concept of Geriatric Emergency and awareness of the uniqueness of the elderly population! Let others champion your ideas! Be Persistent - long process - takes nerve and toughness Others Champion “There’s no limit to what you can achieve if you don’t mind who gets the credit” Be Persistent - long process - takes nerve and toughness Others Champion “There’s no limit to what you can achieve if you don’t mind who gets the credit”

26. Recommendations - Local Areas to explore: 1) What geriatric educational needs do ED staff have and can we utilize the tools developed by SAEM ? 2) How prevalent is ageism in the ED setting and how can it be addressed? Education & ageism: -the skills, knowledge and attitudes of ED staff need to be assessed re: Geriatrics -based on assessment need for geriatric and emergency staff to plan and formalize geriatric emergency training -tools to use - - - Ageism and lack of interest -lit. suggests education on special needs of the elderly, and normal aging will provide a more balance frame of reference to combat ageism - Palmore Facts on Aging Quiz should be part of the geriatric curriculum for ED staff training to develop positive attitudes towards geriatrics Education & ageism: -the skills, knowledge and attitudes of ED staff need to be assessed re: Geriatrics -based on assessment need for geriatric and emergency staff to plan and formalize geriatric emergency training -tools to use - - - Ageism and lack of interest -lit. suggests education on special needs of the elderly, and normal aging will provide a more balance frame of reference to combat ageism - Palmore Facts on Aging Quiz should be part of the geriatric curriculum for ED staff training to develop positive attitudes towards geriatrics

27. Recommendations - Local Just do it! (organizational learning) * Be willing to make mistakes and learn from them * Be willing to trial, pilot, and evaluate in order to build your knowledge * Be willing to share what you’ve done and learned with others* Be willing to make mistakes and learn from them * Be willing to trial, pilot, and evaluate in order to build your knowledge * Be willing to share what you’ve done and learned with others

28. Recommendations- Provincial Regional Geriatric Program take the lead in: - increasing the awareness of Geriatricians of the issue - co-ordinating and information sharing of Geriatric Emergency initiatives Regional Geriatric Program - connection and access to geriatricians - resources to foster communication/ coordination i.e.. web site, collaboration with OHA, DHC, MOH, OGA - Provincial forum RGP’s of OntarioRegional Geriatric Program - connection and access to geriatricians - resources to foster communication/ coordination i.e.. web site, collaboration with OHA, DHC, MOH, OGA - Provincial forum RGP’s of Ontario

29. Recommendations - Provincial Regional Geriatric Program take the lead in: -establishing a forum to bring ED physicians and Geriatricians together to establish an alliance as done in the U.S. (opinion leaders, advocate, lobby for resources, participate with MOH in restructuring emergency, develop outcome indicators) US SAEM - alliance/ working groups between American Geriatric Society and Society of Academic Emergency Physicians web sites - www. saem.org - www.americangeriatrics.org CANADA CAEP and the Canadian Society of Geriatrics (Executive geriatrician in the RGP- Dr. Bill Dalziel/ Dr. Gary Naglie) ROLE of Alliance - to develop opinion leaders in Geriatric Emergency - to increase hospital administration’s awareness of the impact of the elderly on hospital resources -to lobby for expanded Geriatric resources in the ED to facilitate appropriate admissions, discharges and proper utilization of resources - become active participants in MOH restructuring of the Emergency Health Care System - develop outcome indicators to continuously monitor, evaluate and improve the emergency care of the elderly -advocate for community resources and primary care reformUS SAEM - alliance/ working groups between American Geriatric Society and Society of Academic Emergency Physicians web sites - www. saem.org - www.americangeriatrics.org CANADA CAEP and the Canadian Society of Geriatrics (Executive geriatrician in the RGP- Dr. Bill Dalziel/ Dr. Gary Naglie) ROLE of Alliance - to develop opinion leaders in Geriatric Emergency - to increase hospital administration’s awareness of the impact of the elderly on hospital resources -to lobby for expanded Geriatric resources in the ED to facilitate appropriate admissions, discharges and proper utilization of resources - become active participants in MOH restructuring of the Emergency Health Care System - develop outcome indicators to continuously monitor, evaluate and improve the emergency care of the elderly -advocate for community resources and primary care reform

30. Recommendations - Provincial Areas to explore: 1) How can we collaborate with the U.S. so all can benefit from the research being done and our collective experiences? (SAEM - Geriatric Emergency Medicine Task Force and Interest Group) SAEM - have the $ , resources -commitment of the American Geriatric Society and John A. Hartford Foundation - list 3 projects, conference Canadian physicians (Geriatric and Emergency CAEP) unaware of initiatives Activities of the Geriatric Task Force and SEAM Geriatric Interest Group www. saem.org www. americangeriatrics.org -a text book entitled “Emergency Geriatric Care” -an instructor’s Manual for Emergency Care of the Elder Person -videotape: elder Person’s in the Emergency Health Care System - videotape: The Recognition of Delirium in the ED -developed a core curriculum in geriatrics for ED Physicians topics of future directions in improving geriatric care: -functional assessment -geriatric health care workers in EDs -preventive health measures -abuse and neglect -altered disease presentation -geriatric trauma -outcome studies of resources used -innovation in Emerg. care delivery -multiple medication and drug interactions - ethical issues SAEM - have the $ , resources -commitment of the American Geriatric Society and John A. Hartford Foundation - list 3 projects, conference Canadian physicians (Geriatric and Emergency CAEP) unaware of initiatives Activities of the Geriatric Task Force and SEAM Geriatric Interest Group www. saem.org www. americangeriatrics.org -a text book entitled “Emergency Geriatric Care” -an instructor’s Manual for Emergency Care of the Elder Person -videotape: elder Person’s in the Emergency Health Care System - videotape: The Recognition of Delirium in the ED -developed a core curriculum in geriatrics for ED Physicians topics of future directions in improving geriatric care: -functional assessment -geriatric health care workers in EDs -preventive health measures -abuse and neglect -altered disease presentation -geriatric trauma -outcome studies of resources used -innovation in Emerg. care delivery -multiple medication and drug interactions - ethical issues

31. Recommendations - Provincial Areas to explore: 2) How can geriatric emergency training be ensured and standardized in curriculums for all emergency staff?

32. Recommendations - Provincial Areas to explore: 3) How can the ED funding issue be championed and supported? 4) How can we work with the MOH and DHCs to address some of the barriers (funding, education, primary care, community supports)?