These two describe how their smaller ED located in a small city in Wisconsin have thrived over the past two months. They credit a strong culture of community, probably based in the “smallness” of their site, with allowing them to see excellent care for older patients – which represent 38% of their total volume — as part of their commitment to their community. They both reinforced the importance of sharing stories of successful outcomes back to the front-line clinicians, doctors and nurses, so that they know why they are doing this work. Also they use selected workflow statistics (number of screens completed) to let staff know how they’re doing. Their system-level lead, Aaron Malsch, pointed out that by maintaining their projects they have seen their 30-day ED returns drop by 40%! This is a strong sell to the hospital administration which appreciates the improvement in one of its key metrics.

Key points:

• Lots of communication from champions to all staff
• Promote a community feel among all caregivers – that the patients are part of the community too
• Share success stories back to the front line
• Express gratitude for small and big wins (“thanks for placing those orders before noon!”) and to interdisciplinary team for participating
• Post positive statistics for all to see
• Remind everyone that these interventions and initiatives improve care for patients and also department function
• Stay focussed on simple goals.

This large-city large hospital was able to develop an entire accredited Age-friendly ED during COVID! How? Nida thinks in part it was because the staff and the institution found it exciting and inspiring to work on something that wasn’t COVID-related – this project gave them something to do that was positive, creative, and developmental that was going to last well beyond the pandemic. One big success they had was maintaining visits to older ED patients by essential care partners during the pandemic. How? By using the power on one negative outcome that could have been avoided by having a care partner present. Again – the power of stories. She also gave some practical pointers for how to make their changes work financially.

Key points:

• Focus on the positive: give staff something that helps their patients AND the department
• Remember that caregivers are essential – both for better patient care and for better hospital functioning
• Keep sustainability in mind from the beginning: think about the finances of interventions
• Find ways to integrate interdisciplinary team into the ED.
• One bad outcome can have a powerful effect on staff and leadership.
• Use stories to change people’s attitudes.

These two are in the process of creating Geriatric EDs in nine hospitals across their system. They talk about the importance of developing a core team and keeping the task as simple as possible: for example, they chose to implement only one initiative – delirium screening — across all sites. This was also strategically important during the pandemic since delirium is often a presenting symptom of COVID. This allows them to feed back “good news stories” to nurses and doctors about the impact their activities are having. And they reinforce the value of encouraging competition between individuals and rewarding high performers: gifts of “rock candy” because “you’re a rock star of geriatric screening!” It seems basic – but it really works. Ula gives a pep-talk on what to do on building your team from a “team of one” to a system. Sometimes you have to kiss a lot of frogs before you find your princes!

Key points:

• Find out what strengths already exist in your system and build on them
• Stay focussed on single changes; don’t try to do many things at once.
• Find key collaborators to work with (your IT partners, system-level planners)
• Tell the stories of patients who had good outcomes because of interventions
• Share data

They acknowledge the devastating impact the pandemic had on the early Geri ED initiatives at their very large ED. However, they scaled down their expectations to core topics – delirium, falls, functional decline, and elder abuse. They mentioned the importance of engaging their core team –because their site is so large – to be the communication with the front line. They reinforced the value of incentives and rewards to the front line. They have some good points about how to educate and integrate part-time and recent hire nurses into geriatric processes. There were some benefits of pandemic-related changes, for example, the increased presence of palliative care in the ED.

Key points:

• Remember new staff and travel nurses also need to be trained and acculturated.
• Decide what you’re going to focus on, for example, elder abuse, delirium, function, and falls
• Pick your battles: know when to push and when not to push.
• Use tracking boards to flag who is performing well and who less well.
• Use competition, reward, and gamification to incentivize individuals, teams, departments, even whole hospitals.
• Recognize that different parts of the same system can be like different little civilizations. Treat them differently.
• “Bravo points” – use incentives for the whole team.

Aaron Malsch, RN, MSN, GCNS-BC
AAH System Geri ED Program Manager
Wisconsin and Illinois
Level 3 Geri ED

Amber Koplitz, MHA, BSN, RN, NE-BC
Manager of Emergency Services,
Aurora Medical Center Washington County
Wisconsin

Pamela Martin, APRN
Geriatric Emergency Medicine
Yale New Haven Health
Department of Geriatrics

Nida Degesys, MD
Medical Director
Geriatric Emergency Department,
University of California at San Francisco

Katie Hunold, MD
Director Geriatric ED
OSU, Columbus Ohio

Lauren Southerland, MD
Director, Geriatric ED
Ohio State University Medical Centre