Impact of outpatient comprehensive geriatric assessments on repeat visits after an emergency department visit

Transcription

1 GERIATRIC MEDICINE Impact of outpatient comprehensive geriatric assessments on repeat visits after an emergency department visit 2018 Canadian Geriatrics Society Meeting 21 April 2018 Presenting Author: Judith Seary Supervisor: Richard Sztramko Co-Authors: Jennifer Kodis, Donna Martunnen, Carol McKenna, Brian Misiaszek, Shawn Mondoux, Mona Sidhu, & Jennifer Thompson

2 Disclosures No conflicts of interest No funding

3 1. McCusker et al Healthcare Quarterly, 12(Sp): Lowthian J. et al Age and Ageing; 46: Costa AP et al Clinical. Practice; 11(6): Health Quality Ontario Emergency Department Return Visit Quality Program. Accessed: 20 April Introduction An emergency department (ED) visit is a sentinel event for an older person ED visits are associated with increased likelihood of adverse outcomes post-discharge including return visits and functional decline 1,2 Risk factors associated with ED use by community dwelling older adults include past use, cognitive impairment, polypharmacy, and reduced mobility 3 ED usage by older adults in Ontario is rising and repeat visits is a growing area of interest for Health Quality Ontario 4

4 Aim Provide timely access to a comprehensive geriatric assessment (CGA) following an ED visit with the aim of delaying the need for further acute care

5 Usual ED Care Patient arrives in ED & is triaged Bedside nursing assessment & investigations MD assessment Referral Discharge Consulting service assessment Preparations to discharge patient Admission

6 Intervention Geriatric Emergency Medicine (GEM) Nurse identifies patients who would benefit from a CGA Outpatient CGA completed within 10 days of ED discharge

7 Referral Criteria Inclusion Criteria Presence of 1 or more geriatric syndrome(s) Community dwelling Age 65 years Discharged from the Juravinski Hospital Emergency Department Seen by the GEM nurse Exclusion Criteria Resident of or awaiting long term care Geriatric assessment in the previous year Intensive home care services No family doctor Unwilling to attend appointment

8 My Recipe for a Happy Clinic Patient with a geriatric issue arrives at clinic Bonus: arrives on time Double bonus: they know what the appointment is for Comes with a source of collateral information Comes with their medications (not a list) Extra bonus: Recent blood work and ECG available

9 Patient arrives in ED & is triaged Bedside nursing assessment & investigations MD assessment Referral Discharge Consulting service assessment Preparations to discharge patient Admission GEM identifies potential patient for clinic & places order set on chart + Bedside nurse informs GEM of plan to discharge GEM confirms available appointment Legend Current ED processes Interactions with current ED processes Outpatient referral process GEM gives instructions to patient Reminder phone call to confirm appointment Appointment within 2 weeks Referral faxed to outpatient clinic

10 Results Number of appointment slots

11 Patient Characteristics Wait time Days between ED visit and appointment (days) 5.79 ± 2.9 Patient characteristics (N=14) Mean age (years) 84.4 ± 6.9 Male 36% Have a GP 100% Appropriate for clinic 100% Appointments (N=14) No show* 0% Accompanied by family member 100% Brought prescribed medications 79% Brought OTC medications 57% * One patient cancelled two days prior to the appointment

12 Interventions (N=14) Stopped a medication 36% Started a medication 43% Titrated a medication 36% New diagnosis made 100% MTO form submitted 14% CCAC form submitted 64% Connected to another resource 86% Follow up geriatric medicine appointment 71% Blood work ordered 50%

13 ED Return Rates Juravinski Hospital ED Return Rates 1 1. CIHI NACRS

14 ED Return Rates Juravinski Hospital ED Return Rates 1 Repeat Visits and Admissions Within ED Visit Admissions 7 days of clinic visit 7.1% (1)* 0% 1 month of clinic visit 7.1% (1) 0% 3 months of clinic visit 14.2% (2) 14.2% (2) 1. CIHI NACRS * Patient sent from clinic to the ED for wound care

15 Limitations Low numbers of a very select group of patients limits the ability to make generalizations Completing a CGA in this format is challenging

16 Next Steps Gather feedback from geriatricians, case managers and residents about the clinic Trial having social workers initiate referrals during times when the GEM nurse is not available

17 Conclusions EDs are an entry point to the healthcare system for older patients Best strategies to reduce repeat visits to EDs and to connect elderly patients to appropriate resources, including geriatric services, are not yet well understood A targeted outpatient CGA may be an effective way to reduce repeat ED visits

18 Acknowledgements Richard Sztramko for supervision and mentorship Division of Geriatric Medicine at McMaster University for in kind financial support and supervision of the clinic Geriatric Medicine trainees for participating for seeing the patients

19 References 1. McCusker et al Safety of discharge of seniors from the emergency department to the community. Healthcare Quarterly, 12 (Sp): Lowthian J. et al Predicting functional decline in older emergency patients the Safe Elderly Emergency Discharge (SEED) project. Age and Ageing; 46: Costa AP et al Risk of emergency department use among communitydwelling older adults: a review of risk factors and screening methods. Clin. Pract.; 11(6): Health Quality Ontario Emergency Department Return Visit Quality Program. Improvement-in-Action/Emergency-Department-Return-Visit-Quality- Program. Accessed: 20 April 2018.

20 Thank you for your attention

21 Team Members Project leads: Judith Seary and Richard Sztramko Executive sponsor: Jennifer Kodis Core team: Shawn Mondoux (Emergency Medicine), Donna Marttunen (Geriatric Emergency Medicine Nurse), Carol McKenna (Clinical Manager), Eleanor Walters (Intake Coordinator) Steering Committee: Brian Misiaszek (Geriatrician), Mona Sidhu (Geriatrician), Jennifer Thompson (Emergency Medicine)

22 Patient Information Sheet