Geriatric ED Quality Improvement SBAR

Situation

The rate of post-ED (emergency department) orders for PCP (primary care providers), Homecare, Physical Therapy consults in the ED, and Out patient Physical Therapy is low for discharged community-dwelling older adults visiting the ED, resulting in a higher rate of revisits.

The goal is to increase the rate of post-ED orders for discharged at-risk community-dwelling older adults.

Background

The Geri ED program was developed to identify at-risk community-dwelling older adults visiting the ED, change their trajectory (reduce revisits & admissions) and return them back to the community by connecting the patient with resources outside the ED.

Geri ED Dashboard

With the advent of the Geri ED Dashboard, we can identify a correlation between low post-ED service orders rates and higher revisit rates for older community-dwelling fallen patients. A structured comparison between sites was developed to highlight this correlation. Currently, the Geri ED program has been implemented and accredited (ACEP Level III accreditation) at 15 of 24 sites. The remaining 9 sites will be implemented and accredited by 2023. One of these 15 sites has ascended to ACEP Level II Geri ED accreditation, which is the first in Wisconsin & Illinois. As part of this site’s goal of improving care for vulnerable older adults, they have significantly increased post-ED service orders.

15 Geri ED site high risk QI study

Usual Care Inclusion criteria

• 14 ED sites that have implemented Geri ED

Usual Care Exclusion criteria:

• 3 sites = < 50% ISAR completion 9 sites = not implemented Geri ED at time of SBAR Comparison Inclusion criteria 1 site = high rate of service to orders (>45% post ED service orders)

High Risk Population characteristics (all sites):

• 2020 data, >3 ISAR, <3 ESI, >65 years old, discharged, Chief Complaint and/or Clinical Impression of Fall

Assessment

The results of the two group comparison strongly suggests an inverse correlation between a low rate of recidivism and high rate of post ED service orders for high risk community dwelling older adults visiting the ED with a fall.

Usual Care group (twelve Level III Geri EDs):

• n= 880 visits
• 6.5% visits with a post ED service order
• 31.6% 30 day revisits,
• 8.5% 72hrs revisit

Comparison group (one Level II Geri ED):

• n= 127 visits
• 47.2% visits with a post ED service order
• 22.0% 30 day revisits,
• 3.9% 72hr revisits

Recommendation

The Geri ED program makes the following recommendations to decrease rate of ED revisits by increasing rate of post ED service orders:

Collaborate with System Emergency Medicine, Nursing, Care Management, Rehab, and Population Health

• Present findings to system Joint ED Leadership committee
• Analyze patterns of practice
  • Identify barriers and opportunities for order placement
• Develop standardized criteria for placing post ED service orders
• Implement system wide ED education
• Develop metric tracking and communication plan
• Reach concensus on placing orders.
  • PCP ordering
    • Resolve issue of one order for two different intentions
      • Establish new PCP provider relationship verses setting follow-up appointment post ED.
    • Develop mechanism for actively setting follow-up PCP appointments prior to ED disposition verses the current passive PCP follow-up ‘instructions’ in AVS (after visit summary)

Create & implement an automated decision support function for providers in ED in the EHR

• Identify parameters for trigger
• Receive feedback and eventual approval from stakeholder committees
• Build and implement trigger
  • Direct link to the suggested order

Setting: Large integrated health care system in the northern mid-west of the United States

Definitions:

• ISAR= Identification of Seniors at Risk tool
• ESI= Emergency Severity Index
• Post-ED orders:
  • PCP= Primary Care Providers, Internal Medicine, Family Practice
  • Homecare= Homecare
  • PT Orders= Physical Therapy consults in the Emergency Department
  • Service to PT= Out patient Physical Therapy

Contributing Faculty

Aaron Malsch

RN, MSN, GCNS-BC

Bio

As the Program Director of the Geriatric Emergency Department Collaborative (GEDC), Aaron Malsch leads and supports the implementation of the Geriatric Emergency Department (GED) model of care internationally. The GEDC is dedicated to improving the quality of care for older people in the emergency department through education, implementation, and evaluation at the individual, unit, site, system, and regional levels. He is board-certified as a Gerontological Clinical Nurse Specialist (GCNS-BC).

Previously, Aaron focused on nursing and inter-professional practice as it relates to the elder population throughout the Advocate Health system of clinics, hospitals, emergency departments, home care services, and long term setting partners. He has developed expertise in rapid, system level implementation, sustainable improvement in practice, research, and demonstrated outcomes. He has also created a nationally recognized Geriatric Emergency Department program with 22 Advocate Health sites achieving ACEP Geri ED accreditation. Aaron contributes nationally to the improvement of care for older adults, as the Chair of the geriatric committee at the Emergency Nurses Association (ENA), GEDC Core Faculty, and reviewer for Geriatric ED Accreditation (GEDA) program at American College of Emergency Physicians.

Publications