Geriatrics in the Emergency Department :

1. Geriatrics in the Emergency Department : MARRIAGE MAYHEM OR

2. ED, Geriatricshave very different Priorities Diagnostic Processes Thinking Personnel

3. Blind MenFeelingan Elephant...

4. ED • What 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 ?

5. 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?

6. BUT

7. But ... You are the same patient/family, with the same problems

8. ED, GERIATRICS SPEAK DIFFERENT LANGUAGES Translation is required ...

9. Enter ... GEM

10. GEM 12 Toronto hospitals Hamilton, Ottawa, Kingston RGP British Columbia, Quebec Cleveland, Ohio etc., etc.

11. GEM in GTA • Sunnybrook • Scarborough Grace, General • North York General • Toronto East General • St. Joseph’s Health Centre • UHN [TWH and TGH] • York Central, Markham Stouffville • St. Michael’s • HRRH [Church St.]

12. GEM Service Models Diverse models Particular to each hospital’s needs , resources

13. Diverse GEM service models • Resource RN • Advanced Practice Nurse • Nurse-Clinician • CNS • Screening tools • Cross-appointed staff

14. 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

15. Role Models Montreal site visits • Jewish General • Royal Victoria • Montreal General

16. Fear Sunnybrook ED biggest fear, introducing GEM: • Increased LOS in ED

17. Reasons for referral • History of falls • Cognitive changes • Possible abuse / neglect • Substance abuse • Caregiver stress • Caregiver hospitalized … /2

18. Reasons for referral (2) • Functional decline • Anxiety • Acute / Chronic Pain • Repeated ED visits / hospitalizations • Placement

19. Referral Sources • Emergency MDs, RNs • Volunteers • Casefinding [computer EDIS] • Community • Consultants • After-Hours Referral Box • Voicemail

20. Geriatric Nurse- Clinician Role • Assessments • Help decide to admit or not • Co-ordinate followup • Geriatric Research • Education

21. GEM stats • Patients seen, 2002 682 • Average per month 56.8 [Range 48 – 73] • Facilitated Discharges 70 %

22. GEM Bedside Assessment • Observation • Cognitive Assessment • Chart Review • Telephone Inquiries, • Professional Followup • Home Support

23. GEM Assessment Tools • Folstein Mini-Mental State • Geriatric Depression Scale [short form] • Confusion Assessment Method • RGP Assessment Form [same for day hospital, clinic, consult team] • Social Work screening tool

24. GEM Links to Community Resources • CCACs • GPs, Consultants • SGS services • Day Care • Lifeline • Volunteer Drivers • Placement

25. GEM Education • Staff Inservices • Orientation of new staff • Informal Education [for staff, caregivers, patients] • Marketing of services, media

26. GEM on Hospital Committees • ‘Crisis Visits to the ED’ group • Community Partnership • General Medicine Pain Collaborative Project • Quarterly Meeting: all GEM nurse-clinicians and all ED social workers • Accreditation, Quality Improvement • ED Renovation

27. Challenges: Clinical • Pain Management • Isolated Seniors / Limited Finances • Crisis Placement • Absence of Convalescent Care

28. Challenges: Triage • Bias Reporting : ‘Failure to Cope’ ‘Social Admission’ ‘Placement’

29. Challenges: Admin. • Marketing • Vacation Relief • Evening Coverage • Rotation with Consult Team

30. Keys to Success • Visibility • Office Location • Previous Clinical Experience • Hands-On Care • Timely Followup • “Practical Tips for Seniors Visiting ED” … /2

31. Keys to Success (2) • Flexibility • Marketing / Orientation • Collaboration with Key Players • Linking to Community Resources • Partnerships • Feedback / ED Evaluation Forms … /3

32. Keys to Success (3) • Clothing • Transportation • Loaner Equipment • Lifeline Vouchers • Pamphlets / Handouts

33. RGP Toronto Network • 24 participating GTA hospitals • Provincial funding • other Ontario RGPs

34. Toronto RGP activities • Leadership • Advocacy • Service • Education • Research

35. Toronto RGP - Core Services provided by members • Outreach teams • Ambulatory care clinics • Internal consultation teams • Geriatric Rehabilitation Units • Acute Geriatric Units • Day Hospitals • Geriatric Emergency Management

36. RGP GEM Task Force • To spread the word, share knowledge • Project Manager hired February, 2002 • Members: 12 hospitals, ED & Geriatrics • Quarterly meetings • Subcommittees ad hoc re screening tools, elder-friendly environment, etc.

37. GEM Task Force Five Initial Priorities • High risk screening tool • Needs Assessment • Geriatrics Education for Professionals • Elder-friendly ED • Policy Paper

38. 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

39. “Toolkit” • Workshop outline • Observation Guide, for elder-friendly ED • High-risk screening tool • Needs assessment, data analysis support • Electronic listserves

40. Ideas for Future GEM • ‘geri area’ in ED • Strategic partnerships between LTC, acute care hospitals [examples] • Research : EMS workers gather information

41. Other suggestions ?

42. RGP Website www.rgp.toronto.on.ca

43. Contact Lisa Newman, MSW MHSc Project Manager RGP GEM Task Force (416) 480-6100 #7334 lisa.newman.a@utoronto.ca

44. Contact Catherine Bald, RN BScN Nurse-Clinician RGP GICT / GEM (416) 480-6100 #3194, pager #1213 Catherine.Bald @sw.ca