Transcript [Poster title]

A Network of
60 Hospitals in 13 LHINS
across Ontario
BETTER HEALTH OUTCOMES : SERVICE, ADVOCACY, RESEARCH AND EDUCATION
Emergency Departments (EDs) are an essential service for the care of
injuries and trauma for everyone. They provide a safety net when the
system of care is disrupted and services are unavailable. ED care is
especially important for seniors who, while approximately 14% of the
population, account for up to 21% of ED encounters. But not all seniors use
EDs more than younger people. An increase in ED usage is primarily seen
for seniors whose age (>75 years) places them at increased risk of the
complex, bio-psycho-social and functional challenges of frailty. When frail
seniors visit emergency departments they have more emergent conditions,
receive more tests, have longer ED stays and are more likely to be admitted
into hospital than younger patients . For frail seniors, an ED admission may
be a sentinel event. Rates of hospitalization, return ED visits and death in
the months following a visit are higher for frail seniors than for younger age
groups
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Item 8
ASSISTED BY HQO
How do patients get to us?
Symptom presentation is complex and atypical
Multiple co-occurring illness
Poly-pharmacy is the rule not the exception
Diagnostic tests may have normal value
Functional/compensatory reserves are limited
Psychosocial circumstances are changing
Support systems are stretched
Risk of hospitalization is high
Capacity for independent living is threatened
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THE GEM PROCESS MODELING
SERVICES AVAILABLE AT GEM HOSPITALS
UNIQUE VULNERABILITIES
OF FRAIL SENIORS
SUMMARY
CCAC, Primary Care, Aging at
Home, Intensive Geriatric
Social Worker call from
community in advance that
patient is coming in
Begins with: Senior
arrives at the
hospital
EMS gives report
Triage nurse
assesses
Nurse does CTAS
assignment
Clerk sends to
waiting room
Clerk registers
Nurse calls to assign
bed
- acute
- subacute
- see and treat
- fast track
10% referred to
GEM nurse right
away
Nurse does
secondary
assessment
Patient has first
contact with GEM
nurse
What do we do once we have them?
- Meditech for visit
- History
- GAIN visits
- Doctor
- EMS
- Primary ED RN
- Family
- Interprofessional
team
- LTC Staff
- NLOT team
- CCAC
- ODP
75%
70
PT, CCAC, SW
assesses
20% referrals to
GEM nurse
generated
50% referred to
GEM nurse
GEM nurse case
finding
GEM Nurse gathers
information
ED doc assesses
Decide to transition
Establish rapport
Conduct
appropriate
assessments
- Get patient story
- Generate
questions
- Screening
- Delirium
- Care Supports
- Medications
- Living Situation
- Falls
- Social assessment
- Skin Assessment
- Nutrition
- Frailty scale
- ADLs, IADLs
- Safety
- Hydration
Physical exam
Assess available
resources to
mobilize
Patient and family
concerns
Assess potential to
go home
Discharge or
admit?
Arrange consults as
needed
- PT, OT, SLP,
Geriatrics, BSO,
CCAC,
Transportation
Communicate
- in hospital
- external
Call GP
Follow up after
doscharge
Assess medical and
social needs
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A Geriatric Emergency Management Nursing Network has emerged as an
evidence informed best practice to help achieve better health outcomes for
frail seniors in the ED. The GEM network is comprised of 97 advanced
practice nurses in 60 EDs in 13 Local Health Integration Networks (LHINs)
across the province. At its recent 9th Annual GEM conference, the network
members worked with a team of facilitators from Health Quality Ontario to
explore core GEM processes in three areas: How do patients get to GEM,
what happens when they get there and what happens afterwards. To inform
this quality exploration an online GEM practice survey was completed by
61% of presently active GEM nurses from 10 LHINs.
The present poster presents background on GEM together with some
preliminary results from the GEM Practice Survey and process maps in the
three areas of GEM practice.
The GEM nursing network was initiated by the Regional Geriatric Programs
(RGPs) of Ontario and is coordinated by the RGP of Toronto.
GOALS OF GEM PROGRAM
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Identification of seniors at risk in the Emergency Department (ED)
Timely, targeted, essential and accurate assessments
Identification of geriatric syndromes
Screening of functional ability
Optimize linkage with community supports
Appropriate referral and disposition
Reduced admission and re-visits to ED and/or hospital
Prevent delirium and functional decline during the ED visit
Enhanced patient safety
Build geriatric capacity throughout the ED
Adapt GEM practices to best meet local needs and services
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SATISFACTION SURVEY RESULTS
OF GEM SERVICES
40
30
29.5%
25%
20
11%
0
6.7%
Screen and Refer Comprehensive
GEM Assessment
Targeted
Geriatric
Assessment
10%
6.6%
Consultations to
Follow-up
Clinical Service
other ED staff assessments for
discharged
patients not seen
by GEM
GEM Capacity
Building
Everyone makes
decision – patient,
team, family
ED Assessment and
Treatment
complete
15%
10
How do we make transitions happen?
Is patient ready
to go home?
Doctor
discharge
(hospital policy)
GEM nurse
coordinate referrals
- CCAC
- Community
pharmacy
- Family doctor
Community
resources
GEM nurse
coordinates/does
paperwork
GEM nurse creates
a summary report
for patient and
sends to referral
and patient
GEM nurse follows
up with referrals
GEM nurse
determines how
patient will get
home
GEM nurse
coordinates
- Home at Last
- Medication
- Transportation
- Settling in service
GEM nurse and
team communicate
with family
GEM nurse and
team collaborate
with team members
BENEFITS OF ASSESSMENT
Family and
caregiver support
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USAGE RATES FOR EIGHT GERIATRIC
ASSESSMENT TOOLS
GEM ensure home
is a safe place
GEM nurse and
internal health team
review results
Admin Duties
Determine level of risk
Assess and clarify elements of frailty
Identify geriatric syndromes
Clarify atypical presentations
Guide appropriate resource utilization
Inform care coordinators and health
system planners
 Communicate concerns to other
stakeholders (geriatric services, family
physician, community services, longterm care home)
Direct admit
(hospital policy)
FACTS ABOUT GEM
RANK ORDERING OF THE PRESENTING
PROBLEMS OF PATIENTS SEEN BY GEM
 Distributed matrix program management model
 Collaborative program rollout
 Team development, training and mentorship
 Linkage with the Nurse Led Outreach Teams and GAIN Clinics
in various LHINS
 Implementation of a common basic GEM model
 Empowerment of adaptations to meet local needs
 Routine risk screening
 Targeted assessment
 Capacity Building within EDs, hospitals, CCACs, Community
Service Agencies and Long-Term Care
 Routine outcome and user satisfaction evaluations
For additional information please
contact:
Kerri Fisher, Coordinator
Regional Geriatric Program of Toronto
Email: kerri.fishersunnybrook.ca
Telephone: 416.480.5881
References:
• Meldon SW, Mion LC, Palmer RM et al. A brief
risk-stratification tool to predict repeat ED visits
and hospitalizations in older patients discharged
from the emergency department. Acad Emerg
Med. 2003;10(3):224-32
• RGPs of Ontario GEM Progress Report 04-05
www.rgps.on.ca
• Central East LHIN GEM Program
Poster was developed by Dr. David Ryan from the resources of the
Regional Geriatric Program of Toronto and the Ontario GEM
Nurse Network