The Basics: Policies, Procedures & Protocols

A quick reference for quality improvements to make any ED more friendly for older adults

by Don Melady

Potential improvements for any ED

Here is a list of potential improvements you could make in any ED to make it more friendly for older adults. Start with the easy ones (on no budget) and progress from there.

  1. A standardized delirium screening process (some examples: Delirium Triage Screen (= Richmond Agitation Sedation Scale + LUNCH backwards ; b-CAM (= Brief Confusion Assessment Method); 4AT, others);
  2. A standardized dementia screening process (Ottawa 3DY; Mini Cog; Six-Item Screener; Short Blessed Test; other)
  3. A standardized assessment of function and functional decline (ISAR = Identifying Seniors At Risk ); Assessment Urgency Algorithm; the InterRAI Screener;
  4. A standardized fall assessment protocol (including mobility assessment, e.g. Timed Up and Go or other);
  5. An approach to identification of elder abuse;
  6. A protocol for medication reconciliation in conjunction with a pharmacist;
  7. A policy to minimize the use of potentially inappropriate medications (Beers’ list, or other hospital-specific strategy, access to an ED-based pharmacist);
  8. A protocol for pain management — do you have a standardized approach with some education and guidance — or does everyone just make it up as they go;
  9. A protocol for accessing palliative care consultation in the ED: do you have a palliative care consultant in your hospital, in your community? Can you establish a firm link with them?
  10. A protocol for accessing Geriatric Psychiatry consultation in the ED;
  11. A suite of order sets for common geriatric ED presentations developed with particular attention to geriatric-appropriate medications and dosing and management plans (e.g. delirium, hip fracture, sepsis, stroke, ACS – you can borrow Mount Sinai’s);
  12. A protocol to standardize and minimize urinary catheter use (we have one — include link to the pdf here);
  13. A protocol to minimize NPO designation and to promote access to appropriate food and drink — in most departments, NPO for all patients is the default and norm even though it means that older patients (who often stay for a long time) who get no benefit from it are left hungry and thirsty;
  14. A policy to promote mobility — lying in bed is rarely good for a person and immobility is a precipitating factor for delirium;
  15. A standardized discharge protocol for patients discharged home that addresses age-specific communication needs (large-font, lay person’s language, clear follow-up plan, evidence that the patient understands the plan) and includes information about the visit (test results, imaging results);
  16. A protocol for family physician notification of visit — the ED visit is just one stop on the continuum of care — it is essential that the primary care provider be aware of what happened there;
  17. A protocol to address transitions of care to residential care (we have one — include link to our pdf);
  18. A protocol to minimize use of physical restraints including use of trained companions/sitters;
  19. Standardized access to geriatric-specific follow-up clinics: comprehensive geriatric assessment clinic, falls clinic, memory clinic, other;  it should be possible to book an outpatient appointment with these clinics as easily as it is to book fracture or thrombosis follow up;
  20. A protocol for post-discharge follow up (phone, telemedicine, other);
  21. Use of volunteer engagement to enhance patient stimulation, mobility, companionship (we have the article from Stacy Stolarz);
  22. Access to transportation services for return to residence (description of Home At Last);
  23. A pathway programme providing easy access to short- or long-term rehabilitation services, including inpatient (it may be possible to develop a connection with a rehabilitation institution in your community and to establish a process for direct transfers from ED – our model with Bridgepoint – Saskatchewan hospital);
  24. Access to an programme providing home assessment of function and safety and care needs;   ideally there should be a way to access that community-care programme directly from the ED to ensure seamless transition to community care; (CCAC access in Ontario – can I find other examples in other provinces?);
  25. Access to and an active relationship with community para-medicine follow up services (can Mike Nolan write something about post-ED discharge follow up by community paramedics)
  26. An outreach programme to residential care homes to enhance quality of care and of ED transfers (description of Nurse-led Outreach Teams – the Halton group? David Ryan at RGP?)