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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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ed geriatrics have very different
ED, Geriatricshave very different

Priorities

Diagnostic Processes

Thinking

Personnel

slide4
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
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?
slide7

But ...

You are the

same

patient/family,

with the same problems

ed geriatrics speak different languages

ED, GERIATRICS SPEAK DIFFERENT LANGUAGES

Translation is required ...

slide10

GEM

12 Toronto hospitals

Hamilton, Ottawa, Kingston RGP

British Columbia, Quebec

Cleveland, Ohio

etc., etc.

gem in gta
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
GEM Service Models

Diverse models

Particular to each hospital’s

needs ,

resources

diverse gem service models
Diverse GEM service models
  • Resource RN
  • Advanced Practice Nurse
  • Nurse-Clinician
  • CNS
  • Screening tools
  • Cross-appointed staff
sunnybrook pioneered gem
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
Role Models

Montreal site visits

  • Jewish General
  • Royal Victoria
  • Montreal General
slide16
Fear

Sunnybrook ED

biggest fear,

introducing GEM:

  • Increased LOS in ED
reasons for referral
Reasons for referral
  • History of falls
  • Cognitive changes
  • Possible abuse / neglect
  • Substance abuse
  • Caregiver stress
  • Caregiver hospitalized

… /2

reasons for referral 2
Reasons for referral (2)
  • Functional decline
  • Anxiety
  • Acute / Chronic Pain
  • Repeated ED visits / hospitalizations
  • Placement
referral sources
Referral Sources
  • Emergency MDs, RNs
  • Volunteers
  • Casefinding [computer EDIS]
  • Community
  • Consultants
  • After-Hours Referral Box
  • Voicemail
geriatric nurse clinician role
Geriatric Nurse- Clinician Role
  • Assessments
  • Help decide to admit or not
  • Co-ordinate followup
  • Geriatric Research
  • Education
gem stats
GEM stats
  • Patients seen, 2002 682
  • Average per month 56.8

[Range 48 – 73]

  • Facilitated Discharges 70 %
gem bedside assessment
GEM Bedside Assessment
  • Observation
  • Cognitive Assessment
  • Chart Review
  • Telephone Inquiries,
  • Professional Followup
  • Home Support
gem assessment tools
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
GEM Links to Community Resources
  • CCACs
  • GPs, Consultants
  • SGS services
  • Day Care
  • Lifeline
  • Volunteer Drivers
  • Placement
gem education
GEM Education
  • Staff Inservices
  • Orientation of new staff
  • Informal Education

[for staff, caregivers, patients]

  • Marketing of services, media
gem on hospital committees
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
Challenges: Clinical
  • Pain Management
  • Isolated Seniors / Limited Finances
  • Crisis Placement
  • Absence of Convalescent Care
challenges triage
Challenges: Triage
  • Bias Reporting :

‘Failure to Cope’

‘Social Admission’

‘Placement’

challenges admin
Challenges: Admin.
  • Marketing
  • Vacation Relief
  • Evening Coverage
  • Rotation with Consult Team
keys to success
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
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
Keys to Success (3)
  • Clothing
  • Transportation
  • Loaner Equipment
  • Lifeline Vouchers
  • Pamphlets / Handouts
rgp toronto network
RGP Toronto Network
  • 24 participating

GTA hospitals

  • Provincial funding
  • other Ontario RGPs
toronto rgp activities
Toronto RGP activities
  • Leadership
  • Advocacy
  • Service
  • Education
  • Research
toronto rgp core services provided by members
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
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
GEM Task Force Five Initial Priorities
  • High risk screening tool
  • Needs Assessment
  • Geriatrics Education for Professionals
  • Elder-friendly ED
  • Policy Paper
consultations to hospitals
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
“Toolkit”
  • Workshop outline
  • Observation Guide, for elder-friendly ED
  • High-risk screening tool
  • Needs assessment, data analysis support
  • Electronic listserves
ideas for future gem
Ideas for Future GEM
  • ‘geri area’ in ED
  • Strategic partnerships between LTC, acute care hospitals [examples]
  • Research : EMS workers gather information
rgp website
RGP Website

www.rgp.toronto.on.ca

contact
Contact

Lisa Newman, MSW MHSc

Project Manager

RGP GEM Task Force

(416) 480-6100 #7334

[email protected]

contact44
Contact

Catherine Bald, RN BScN

Nurse-Clinician

RGP GICT / GEM

(416) 480-6100 #3194,

pager #1213

Catherine.Bald @sw.ca

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