Geriatric Emergency Management OHA 2005

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Geriatric Emergency ManagementOHA 2005

• Barbara Liu, MD, FRCPC
• Program Director,
• Regional Geriatric Program of Toronto
• Sunnybrook Womens College Health Science Centre

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Objectives

• Review utilization of ED services by seniors in
  Ontario
• Review impact of Geriatric Emergency Management
  (GEM) on health services utilization
• RGPs of Ontario GEM model and evaluation plan

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Distribution of visits by age(CIHI 2005)
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ED visit rates highest amongst very young and
very old (CIHI 2005)
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Older patients have longer length of stay in ED
regardless of acuity (CIHI 2005)
CTAS Canadian Triage and Acuity Scale
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Two Paradigms
ED Geriatrics

• Single complaint
• Acute
• Diagnose and treat
• Rapid disposition

• Multiple problems
• Medical
• Functional
• Social
• Acute on chronic, subacute
• Control symptoms, maximize function, enhance
  quality of life
• Continuity of care

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ED visit is a sentinel event

• 10 3 month mortality
• health service utilization
• up to 24 return to ED in 3 months
• up to 44 return to ED in 6 months
• 25 are hospitalized

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Consequences

• Incomplete, inaccurate assessments
• inappropriate disposition of patients
• readmission to ER or hospital
• Functional decline
• Institutionalization

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Geriatric Emergency Management (GEM)

• Team approach to complex issues
• Collaboration of geriatric approach within
  context of ED demands
• Identification and assessment of geriatric
  syndromes and other missed diagnoses
• linkage to community resources
• referral for further assessment as needed
• targeted to high risk seniors
• Usually nursing follow up services

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GEM Reduction in hospital admissionsDEED II
Study Caplan JAGS 2004

• N739, RCT
• all hospital admissions at 30 days
• 16.5 vs. 22.2 p0.048
• Relative risk reduction 25
• NNT 18
• emergency hospital admissions at 18 mos
• 44.4 vs. 54.3 p0.007
• Relative risk reduction 18
• NNT10

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GEM Reduction in nursing home admissionsMion et
al, Annals Emerg Med 2003

• N650, RCT
• nursing home admission at 30 days
• 0.7 vs. 3 OR0.21 (0.05-.099)
• more effective in high risk subgroup

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GEM Reduction in repeat ED visits Guttman Acad
Emerg Med 2004

• n1724, Historical control group
• repeat ED visits at 14 days
• 12.9 vs 16.1
• relative risk reduction 20
• NNT 31
• Adjusted relative risk 0.74 (0.57-0.96)
  controlling for disease severity and functional
  status

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GEM Improved functional outcomesMcCusker JAGS
2001

• N388
• Reduced rate of functional decline at 4 month
  adjusted odds ratio0.53 (0.31-0.91)
• Increased communication and linkage with
  community resources
• Economics - cost ratio 0.94 (0.75 - 1.17)
• subgroup who visited ED in past 30 days 0.66
  (0.44-0.97)
• Ann Emerg Med 2003
• similar finding in DEED II study

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GEM Ontario Initiative

• 8 new, full-time, permanent RN clinical educator
  positions across Ontario
• Goals
• Service development
• Improve patient outcomes
• Capacity building

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Triage Risk Screening Tool (TRST)

• Cognitive impairment
• difficulty mobility, transfers or falls
• 5 or more medications
• ED visit past 30 days, hospitalization in past 90
  days
• RN professional recommendation

Meldon et al, Acad Emerg Med 200310224
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(No Transcript)
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GEM Goal Improved Patient Outcomes

• Provide discharge recommendations
• Facilitate referrals to geriatric and other
  health services
• Enhanced communication with careproviders
• Increase linkage to community services
• Reduce rate of readmission to ED
• Reduce rate of admission to hospital

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GEM Goal Capacity Building

• Understand and address learning needs in ED
• understand the needs of long term care and CCAC
  partners
• Summarize lessons learned individually and
  programmatically
• Identify effective models of GEM service
• Satisfy stakeholders

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Control Group

• Match for age, gender and CTAS rating
• two groups
• Historical control
• Other hospital without GEM

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Keys to success

• Time involved in indirect care and capacity
  building
• integration with ED staff
• high risk identification
• post discharge patient resources

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Summary

• Seniors are disproportionately represented in ED
  visits in Ontario
• ED visit opportunity to intervene
• GEM can
• ? hospital admissions
• ? repeat ED visits
• ? NH admissions
• improve functional outcomes
• economically favourable
• capacity building, target high risk, follow up
  resources

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Acknowledgments

• Regional Geriatric Program of Toronto
• Regional Geriatric Program Central, Hamilton
• Southeastern Ontario Regional Geriatric Program,
  Kingston
• Southwestern Ontario Regional Geriatric Program,
  London
• Regional Geriatric Assessment Program, Ottawa
• GEM nurses in Ontario

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References

• RGPs of ON GEM Progress Report 04-05
  www.rgps.on.ca
• DEED II Caplan G, et al. JAGS 2004521417-1423
• Systematic Review Hastings, S Academic Emerg Med
  200512978-986
• Aminzadeh and Dalziel. Ann Emerg Med
  200239238-247
• Understanding Emergency Department Wait Times
  CIHI report 2005