# 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

Geri ED Dashboard Screen shot: 12 ED site Group (Usual Care group)

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

Geri ED Dashboard Screen shot: 12 ED site Group (Usual Care group)

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