GEM stands for Geriatric Emergency Management: it is the Ontario programme that spread nurse -led geriatric case management widely. GEM is focused on specialized nursing services for community-dwelling frail older people in Emergency Departments.

Older people represent as many as 30% of the patients seen in Emergency Departments, more than any other age group. Illness complexity, hospital admission rates, lengths of stay and risk of functional decline are also highest for seniors. Indeed, emergency department visits are often sentinel events for older people, threatening loss of independence, health and well-being. By providing specialized frailty-friendly services in Emergency Departments, decline and loss of independence can often be prevented or postponed and repeat ED visits can be minimized.

Emergency departments have many specialized services to meet unique population needs such as trauma, mental health, sexual assault and domestic violence. The needs of frail older people are similarly unique and the presence of a specialized geriatric case management nurse can help EDs manage frail older people more effectively. GEM nurses bring with them knowledge of aging, understanding of the common geriatric syndromes and atypical presentation patterns, as well as intervention and prevention strategies that will help seniors maintain their level of independence and well-being. As a specialized role, GEM nurses focus on clinical consultation with patients and ED staff, education of patients/families and ED staff and in capacity building initiatives within their community and through provincial liaison. This last role is particularly important function in providing leadership for senior-friendly change.

When new GEM positions are developed it is important that, in addition to working with frail seniors in the ED, GEM nurses also work to build capacity at a system level in their communities through the provision of educational support and service planning for example in long-term, primary care and home care.

Not all seniors who go to the ED needs to see a GEM nurse. GEM nurses focus their attention on seniors with complex medical, functional and/or psychosocial problems who are frail and most at risk of losing independence.

Typically, these frail seniors are aged 75 years or older and their problems might include one or more of the geriatric syndromes – falls, delirium, dementia, depression, elder abuse, pressure ulcers, incontinence, malnutrition and functional decline. The expertise of the GEM nurse can assist in the assessment of atypical presentations of acute medical conditions.

We encourage the use of a routine standardized risk screen for all older people who come to the ED. Scores on the risk screen completed during primary assessment will indicate the need for a referral to the GEM nurse.

Paramedic and ED staff can also ask GEM nurses to see older people when they have an intuition or “gut feeling” that the GEM nurse could help even if the risk screen score is not high. Patients and their family members might also ask for the GEM nurse to become involved.

The GEM nurse completes a holistic, brief, focused assessment of the older person experiencing a medical emergency. Based on findings during the assessment, the GEM nurse will prepare a plan in collaboration with the patient and any care-givers/family members. Recommendations may include further assessment/interventions within the ED or inpatient unit and will always provide suggestions for post discharge linkage to services. The person’s primary health care practitioner is usually contacted.

With the person’s permission, family and other support persons are encouraged to be part of the GEM service.

For frail seniors at high risk who go to the Emergency Department when GEM nurses are unavailable, time permitting, the GEM nurse will respond to requests for telephone follow-up or assistance. Some EDs have developed a protocol for holding patients in the ED for up to 12 hours for further assessment by the GEM nurse and the interdisciplinary team.

Our recent surveys indicate that seeing a GEM nurse does not increase ED wait times. By decreasing admission rates, (and thus freeing up inpatient beds) and by decreasing unnecessary return visits, GEM nurse interventions can significantly improve both flow and patient satisfaction.