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Geriatrics in the Emergency Department : PowerPoint PPT Presentation


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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 :

MARRIAGE

MAYHEM

OR


ED, Geriatricshave very different

Priorities

Diagnostic Processes

Thinking

Personnel


Blind MenFeelingan Elephant...


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 ?


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?


BUT


But ...

You are the

same

patient/family,

with the same problems


ED, GERIATRICS SPEAK DIFFERENT LANGUAGES

Translation is required ...


Enter ...

GEM


GEM

12 Toronto hospitals

Hamilton, Ottawa, Kingston RGP

British Columbia, Quebec

Cleveland, Ohio

etc., etc.


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.]


GEM Service Models

Diverse models

Particular to each hospital’s

needs ,

resources


Diverse GEM service models

  • Resource RN

  • Advanced Practice Nurse

  • Nurse-Clinician

  • CNS

  • Screening tools

  • Cross-appointed staff


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


Role Models

Montreal site visits

  • Jewish General

  • Royal Victoria

  • Montreal General


Fear

Sunnybrook ED

biggest fear,

introducing GEM:

  • Increased LOS in ED


Reasons for referral

  • History of falls

  • Cognitive changes

  • Possible abuse / neglect

  • Substance abuse

  • Caregiver stress

  • Caregiver hospitalized

    … /2


Reasons for referral (2)

  • Functional decline

  • Anxiety

  • Acute / Chronic Pain

  • Repeated ED visits / hospitalizations

  • Placement


Referral Sources

  • Emergency MDs, RNs

  • Volunteers

  • Casefinding [computer EDIS]

  • Community

  • Consultants

  • After-Hours Referral Box

  • Voicemail


Geriatric Nurse- Clinician Role

  • Assessments

  • Help decide to admit or not

  • Co-ordinate followup

  • Geriatric Research

  • Education


GEM stats

  • Patients seen, 2002 682

  • Average per month 56.8

    [Range 48 – 73]

  • Facilitated Discharges 70 %


GEM Bedside Assessment

  • Observation

  • Cognitive Assessment

  • Chart Review

  • Telephone Inquiries,

  • Professional Followup

  • Home Support


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


GEM Links to Community Resources

  • CCACs

  • GPs, Consultants

  • SGS services

  • Day Care

  • Lifeline

  • Volunteer Drivers

  • Placement


GEM Education

  • Staff Inservices

  • Orientation of new staff

  • Informal Education

    [for staff, caregivers, patients]

  • Marketing of services, media


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


Challenges: Clinical

  • Pain Management

  • Isolated Seniors / Limited Finances

  • Crisis Placement

  • Absence of Convalescent Care


Challenges: Triage

  • Bias Reporting :

    ‘Failure to Cope’

    ‘Social Admission’

    ‘Placement’


Challenges: Admin.

  • Marketing

  • Vacation Relief

  • Evening Coverage

  • Rotation with Consult Team


Keys to Success

  • Visibility

  • Office Location

  • Previous Clinical Experience

  • Hands-On Care

  • Timely Followup

  • “Practical Tips for Seniors Visiting ED”

    … /2


Keys to Success (2)

  • Flexibility

  • Marketing / Orientation

  • Collaboration with Key Players

  • Linking to Community Resources

  • Partnerships

  • Feedback / ED Evaluation Forms

    … /3


Keys to Success (3)

  • Clothing

  • Transportation

  • Loaner Equipment

  • Lifeline Vouchers

  • Pamphlets / Handouts


RGP Toronto Network

  • 24 participating

    GTA hospitals

  • Provincial funding

  • other Ontario RGPs


Toronto RGP activities

  • Leadership

  • Advocacy

  • Service

  • Education

  • Research


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


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.


GEM Task Force Five Initial Priorities

  • High risk screening tool

  • Needs Assessment

  • Geriatrics Education for Professionals

  • Elder-friendly ED

  • Policy Paper


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


“Toolkit”

  • Workshop outline

  • Observation Guide, for elder-friendly ED

  • High-risk screening tool

  • Needs assessment, data analysis support

  • Electronic listserves


Ideas for Future GEM

  • ‘geri area’ in ED

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

  • Research : EMS workers gather information


Other suggestions ?


RGP Website

www.rgp.toronto.on.ca


Contact

Lisa Newman, MSW MHSc

Project Manager

RGP GEM Task Force

(416) 480-6100 #7334

[email protected]


Contact

Catherine Bald, RN BScN

Nurse-Clinician

RGP GICT / GEM

(416) 480-6100 #3194,

pager #1213

Catherine.Bald @sw.ca


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