An RNAO Advanced Clinical Practice Fellowship Project Kassandra Johnson, BScN, RN
Queensway Carleton Hospital QCH serves a population of over 400,000 in the greater Ottawa Valley Approx. 72, 800 ED visits per year Average 200 visits per day Our ED has 20 Observation beds, 2 Resus beds and a low acuity area with 14 assessment rooms Staff of approx. 130 nurses and 55 ED physicians
Gatineau Hospital Hull Hospital Montfort Hospital General Hospital Civic Hospital Queensway Carleton Hospital
The Elderly in the QCH ED 24% of all patients are over the age of 65 A chart audit revealed that 46 % of elderly patients have a repeat unplanned visit to the ED within 30 days 80% of elderly patients seen in the QCH ED are discharged back into the community A survey of QCH ED nurses revealed that they felt the greatest barriers to the quality of the elder care that they provide were lack of knowledge about the geriatric specialty, inadequate staffing of interdisciplinary services and lack of adaptive aides in the department Nurses reported feelings of guilt and helplessness related to the barriers they face in providing quality care to their geriatric patients
The Evidence The current model of ED care was designed for the acutely ill and injured patient, not a medically complicated, functionally impaired geriatric patient (Adams et al) ED processes are usually inadequate and inhospitable for the older person (Adams et al) Common deficiencies in the care of this high-risk population in the ED setting include failure to recognize problems that could benefit from more careful assessment, and failure to refer to appropriate community services (McCusker et al) As a result of these oversights the elderly client can become vulnerable to adverse functional outcomes, noncompliance with medications or post-discharge instructions (Meldon et al.) Detection and risk stratification of patients at risk for adverse outcomes would allow targeted comprehensive geriatric assessment and specific interventions to address unmet medical and social needs (Meldon et al) In our current healthcare system, if you re not working in paediatrics, you re working in geriatrics!
So, we wanted to improve the care of elderly patients in our Emerg...but how?!
Our Methods Extensive literature reviews concerning best practice guidelines for geriatric care in the Emergency Department Consultations with Geriatric Specialists from across Canada, including Dr. Belinda Parke, Dr. Jane McCusker and Dr. Josee Verdon Review of current documentation and practices in ED s nationwide Consultation and collaboration with QCH ED staff During the review no evidence was found of any current tool used by frontline Emergency staff for assessment, care and discharge planning of geriatric patients lots for pediatrics Most hospitals have advanced practice geriatric nurse programs in their ED s, however they can t assess all geriatric patients in the department
New Tools and Resources Geriatric Emergency Nursing Flowsheet Community Resources Information Sheet Discharge Information Sheet
Geriatric Emergency Nursing Flowsheet To be used for all patients 70 years of age and older ISAR screening tool is included on the front cover to predict risk of return without intervention Contains geriatric specific assessment triggers Assessment tools such as the Pain Assessment in Advanced Dementia (PAINAD) tool, the Dementia Quick Screen and the Confusion Assessment Method (CAM) Based on geriatric domains (ADL s, Cognition, Mobility, Communication, Affect, Mobility, Environment, etc.) NEW risk identification section contains proposals and triggers to promote best practices and gives direction to frontline staff for appropriate follow-up, referrals and interventions
Community Resources Guide
Discharge Information Keeps patients and families informed, involved and accountable Summarizes treatment, diagnosis and follow up instructions Serves as a communication tool with primary care
More work to be done. Education Ongoing education for staff to improve awareness of geriatrics as a specialty area Emphasize the benefits of assessment tools by utilizing case studies to standardize practice Regular chart auditing and targeted education based on findings Support Ensure geriatric care is a strategic priority, align with departmental priorities Utilize Geriatric Flowsheet to document continued need for more interprofessional services in the ED Follow up with community partners to ensure appropriateness of community referrals coming from our department
Kassandra Johnson, BScN, RN Emergency Department Queensway Carleton Hospital kjohnson@qch.on.ca 613-721-2000 ext.4333
References Adams and Gerson (March 2003).Geriatric Care Model. Academy of Emergency Medicine Journal. Vol. 10, No. 3. Canadian Institute for Health Information (2010). Seniors Use of Emergency Departments in Ontario, 2004 2005 to 2008 2009. Retrieved on September 20th, 2011 from www.cihi.ca McCusker et al. (March 2003). Rapid Two-stage Emergency Department Intervention for Seniors: Impact on Continuity of Care. Academy of Emergency Medicine Journal. Vol. 10, No. 3. McCusker, Jane. (July 25th, 2012). Personal communication. Meldon et al. (March 2003). A Brief Risk-stratification Tool to Predict Repeat Emergency Department Visits and Hospitalizations in Older Patients Discharged from the Emergency Department. Academy of Emergency Medicine Journal. Vol. 10, No. 3. Parke, Belinda. (July-September 2012). Personal communications. Queensway Carleton Hospital (2012). Emergency Department Geriatric Flowsheet. [Internal patient chart document]. Verdon, Josee. (July 2012). Personal communications.