A Geriatric ED Checklist

Staffing

1. A physician champion or medical director with some focussed education specifically relevant to the provision of emergency care of older people should be identified by administration.
2. An identified nurse case manager or transitional care nurse or equivalent present in the ED for at least 66 hours/week of coverage with responsibility for complex geriatric patient and responsibility for capacity development/performance improvement within the ED.
3. At least two members of an inter-disciplinary geriatric assessment team should be available to the ED: physiotherapy, occupational therapy, social work, pharmacy.
4. At least one member of the executive/administrative team of the hospital should have, as a part of her portfolio, supervision of the Geriatric ED programme and be actively committed to enhancing geriatric ED care.
5. A patient advisor or patient council should be appointed and be able to provide at least monthly input on potential for quality improvement.

Education

Staff Physicians

Educating staff physicians about the care of older patients is critically important in a senior-friendly ED. This education can be accomplished in different ways: identified core readings, accredited CME, in-house lectures, self-directed learning activities may all respond to a department’s needs.
Some examples of possible educational activities:

• Geri-EM.com modules for accredited CME;
• The Mount Sinai Toronto Geriatric Review course;
• The Mount Sinai New York Geriatric Review course;
• The University of Iowa Geriatric Lecture Series.

Appropriate education will relate to the eight domains of Geriatric Emergency Medicine as defined by Hogan et al.:

• Atypical presentations of disease
• Trauma including falls
• Cognitive and Behavioural disorders
• Emergency intervention modifications
• Medication management/Polypharmacy
• Transitions of care
• Effect of comorbid conditions/Polymorbidity
• End-of-life care

Nursing Personnel

Educating nursing personnel about the care of older patients is critically important in a senior-friendly ED. Some examples:

• Geri-EM.com modules;
• GENE course from Emergency Nurses Association;
• Emergency Department nursing modules from NICHE;
• Locally developed nursing education modules.

Policies, Procedures & Protocols

1. A protocol to older patients at particular risk of functional decline – for example, the use of the Triage Risk Screening Tool;
2. A standardized delirium screening process (examples: DTS; CAM; 4AT, other); See the Mount Sinai Emergency Nursing Care Record.
3. A standardized dementia screening process (Ottawa 3DY; Mini Cog; SIS; Short Blessed Test; other);
4. A standardized assessment of function and functional decline (ISAR; AUA; interRAI Screener; other);
5. A standardized fall assessment protocol (including mobility assessment, e.g. Timed Up and Go or other) (See the Mount Sinai Emergency Nursing Care Record);
6. An approach to identification of elder abuse;
7. A protocol for pain;
8. A protocol for medication reconciliation in conjunction with a pharmacist;
9. A policy to minimize the use of potentially inappropriate medications (Beers’ list, or other hospital-specific strategy);
10. A protocol for accessing palliative care consultation in the ED;
11. A protocol for accessing Geriatric Psychiatry consultation in the ED;
12. At least five 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);
13. A policy to standardize and minimize urinary catheter use;
14. A policy to minimize NPO designation and to promote access to appropriate food and drink;
15. A policy to promote mobility;
16. 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 of patient communication);
17. A protocol for PCP notification;
18. A protocol to address transitions of care to residential care;
19. A protocol to minimize use of physical restraints including use of trained companions/sitters;
20. A well-established protocol allowing for further appropriate geriatric assessment not requiring admission (e.g. Hold Overnight Orders);
21. Standardized access to geriatric specific follow-up clinics: comprehensive geriatric assessment clinic, falls clinic, memory clinic, other;
22. A protocol for post-discharge follow up (phone, telemedicine, other) (e.g. reaching out directly to family physicians);
23. Use of volunteer engagement to enhance patient stimulation, mobility, companionship;
24. Access to transportation services for return to residence;
25. A pathway programme providing easy access to short- or long-term rehabilitation services, including inpatient;
26. Access to an outreach programme providing home assessment of function and safety (see the Specialized Geriatric Services Referral Form form Mount Sinai Hospital);
27. Access to an active relationship with community paramedicine follow up services;
28. An outreach programme to residential care homes to enhance quality of care and of ED transfers.

Quality Improvement

here should be evidence of efforts to ensure effective and appropriate utilization of above policies and protocols using standard QI processes like Plan-Do-Study-Act cycles and outcome measures (see below).

Outcomes Measures

The ED should track metrics for structures, processes, and outcomes related to the following criteria.

1. Numbers of older adults with repeat ED visits
2. Numbers of older adults with repeat hospital admissions
3. Number of older adults staying >8 hours in the ED
4. Mortality data for patients according to designated diagnosis
5. Numbers of older adults admitted to the hospital with specific chief complaints and admitting diagnosis
6. Numbers of older adults discharged to home, long-term care, rehabilitation with ED diagnosis and chief complaints
7. Numbers of patients screening positively on applicable screen(s) (e.g. delirium, functional decline, falls, elder abuse)
8. Numbers of patients accessing a referral pathway for positively screened patients
(e.g. assessment by an in-department assessment team or referral to a Falls or Memory Clinic)
9. Percentage of eligible positively screened patients who are referred appropriately
10. Percentage of eligible positively screened patients who complete the referral
11. Outcomes of such referral

Environment and Equipment

Equipment and supplies

1. Easy in-department access to all of the following:
2. Four-point walkers
3. Canes
4. Non-slip socks
5. Pressure-ulcer reducing mattresses and pillows
6. Blanket warmer
7. Hearing assist devices
8. Bedside commode
9. Condom catheters
10. Low beds
11. Some recline-able arm chairs

Physical environment

It is not necessary to establish a separate space reserved only for older people. However attention to the following criteria will improve the ED experience for patients of all ages:

1. Access to natural light
2. Efforts at noise reduction (separate enclosed rooms)
3. Non-slip floors
4. Adequate hand rails
5. High-quality signage and way-finding
6. Wheel-chair accessible toilets
7. Availability of raised toilet seats
8. Large face analog clocks in each room
9. Easy access to food and drink
10. Ample seating for visitors and family (at least 2/room)

For the complete Geriatric Emergency Department Guidelines please visit acep.org/geriedguidelines/

References & resources

• Checklist English  from geriatric-ed.com
• Checklist Français from geriatric-ed.com
• McCusker J, Verdon J, Vadeboncoeur A, et al. The elder-friendly emergency department assessment tool: development of a quality assessment tool for emergency department-based geriatric care. J Am Geriatr Soc. 2012;60: 1534-1539.

Faculty

Don Melady

MD

Bio

Dr. Don Melady is an emergency physician at Mount Sinai Hospital in Toronto, Canada and a founding member of the Geriatric Emergency Department Collaborative. He is the author of the website www.geri-EM.com – a CME accredited program for geriatric emergency medicine education – and the chair of the Geriatric EM committee of the International Federation of Emergency Medicine.

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