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Geriatrics in the Emergency Department :. MARRIAGE. MAYHEM. OR. ED, Geriatrics have very different. Priorities Diagnostic Processes Thinking Personnel. Blind Men Feeling an Elephant. ED What is your chief diagnosis here today ? Is it life-threatening ?

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Geriatrics in the emergency department l.jpg

Geriatrics in the Emergency Department :

MARRIAGE

MAYHEM

OR


Ed geriatrics have very different l.jpg

ED, Geriatricshave very different

Priorities

Diagnostic Processes

Thinking

Personnel


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Blind MenFeelingan Elephant...


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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 ?


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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?


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BUT


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But ...

You are the

same

patient/family,

with the same problems


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ED, GERIATRICS SPEAK DIFFERENT LANGUAGES

Translation is required ...


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Enter ...

GEM


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GEM

12 Toronto hospitals

Hamilton, Ottawa, Kingston RGP

British Columbia, Quebec

Cleveland, Ohio

etc., etc.


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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.]


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GEM Service Models

Diverse models

Particular to each hospital’s

needs ,

resources


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Diverse GEM service models

  • Resource RN

  • Advanced Practice Nurse

  • Nurse-Clinician

  • CNS

  • Screening tools

  • Cross-appointed staff


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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


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Role Models

Montreal site visits

  • Jewish General

  • Royal Victoria

  • Montreal General


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Fear

Sunnybrook ED

biggest fear,

introducing GEM:

  • Increased LOS in ED


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Reasons for referral

  • History of falls

  • Cognitive changes

  • Possible abuse / neglect

  • Substance abuse

  • Caregiver stress

  • Caregiver hospitalized

    … /2


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Reasons for referral (2)

  • Functional decline

  • Anxiety

  • Acute / Chronic Pain

  • Repeated ED visits / hospitalizations

  • Placement


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Referral Sources

  • Emergency MDs, RNs

  • Volunteers

  • Casefinding [computer EDIS]

  • Community

  • Consultants

  • After-Hours Referral Box

  • Voicemail


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Geriatric Nurse- Clinician Role

  • Assessments

  • Help decide to admit or not

  • Co-ordinate followup

  • Geriatric Research

  • Education


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GEM stats

  • Patients seen, 2002 682

  • Average per month 56.8

    [Range 48 – 73]

  • Facilitated Discharges 70 %


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GEM Bedside Assessment

  • Observation

  • Cognitive Assessment

  • Chart Review

  • Telephone Inquiries,

  • Professional Followup

  • Home Support


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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


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GEM Links to Community Resources

  • CCACs

  • GPs, Consultants

  • SGS services

  • Day Care

  • Lifeline

  • Volunteer Drivers

  • Placement


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GEM Education

  • Staff Inservices

  • Orientation of new staff

  • Informal Education

    [for staff, caregivers, patients]

  • Marketing of services, media


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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


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Challenges: Clinical

  • Pain Management

  • Isolated Seniors / Limited Finances

  • Crisis Placement

  • Absence of Convalescent Care


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Challenges: Triage

  • Bias Reporting :

    ‘Failure to Cope’

    ‘Social Admission’

    ‘Placement’


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Challenges: Admin.

  • Marketing

  • Vacation Relief

  • Evening Coverage

  • Rotation with Consult Team


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Keys to Success

  • Visibility

  • Office Location

  • Previous Clinical Experience

  • Hands-On Care

  • Timely Followup

  • “Practical Tips for Seniors Visiting ED”

    … /2


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Keys to Success (2)

  • Flexibility

  • Marketing / Orientation

  • Collaboration with Key Players

  • Linking to Community Resources

  • Partnerships

  • Feedback / ED Evaluation Forms

    … /3


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Keys to Success (3)

  • Clothing

  • Transportation

  • Loaner Equipment

  • Lifeline Vouchers

  • Pamphlets / Handouts


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RGP Toronto Network

  • 24 participating

    GTA hospitals

  • Provincial funding

  • other Ontario RGPs


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Toronto RGP activities

  • Leadership

  • Advocacy

  • Service

  • Education

  • Research


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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


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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.


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GEM Task Force Five Initial Priorities

  • High risk screening tool

  • Needs Assessment

  • Geriatrics Education for Professionals

  • Elder-friendly ED

  • Policy Paper


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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


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“Toolkit”

  • Workshop outline

  • Observation Guide, for elder-friendly ED

  • High-risk screening tool

  • Needs assessment, data analysis support

  • Electronic listserves


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Ideas for Future GEM

  • ‘geri area’ in ED

  • Strategic partnerships between LTC, acute care hospitals [examples]

  • Research : EMS workers gather information


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Other suggestions ?


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RGP Website

www.rgp.toronto.on.ca


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Contact

Lisa Newman, MSW MHSc

Project Manager

RGP GEM Task Force

(416) 480-6100 #7334

[email protected]


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Contact

Catherine Bald, RN BScN

Nurse-Clinician

RGP GICT / GEM

(416) 480-6100 #3194,

pager #1213

Catherine.Bald @sw.ca


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