# The Basics: Policies, Procedures & Protocols

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.

A standardized delirium screening process (some examples: Delirium Triage Screen (= Richmond Agitation Sedation Scale + LUNCH backwards ; b-CAM (= Brief Confusion Assessment Method); 4AT, others);

A standardized dementia screening process (Ottawa 3DY; Mini Cog; Six-Item Screener; Short Blessed Test; other)

A standardized assessment of function and functional decline (ISAR = Identifying Seniors At Risk ); Assessment Urgency Algorithm; the InterRAI Screener;

A standardized fall assessment protocol (including mobility assessment, e.g. Timed Up and Go or other);

An approach to identification of elder abuse;

A protocol for medication reconciliation in conjunction with a pharmacist;

A policy to minimize the use of potentially inappropriate medications (Beers’ list, or other hospital-specific strategy, access to an ED-based pharmacist);

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;

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?

A protocol for accessing Geriatric Psychiatry consultation in the ED;

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);

A protocol to standardize and minimize urinary catheter use (we have one — include link to the pdf here);

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;

A policy to promote mobility — lying in bed is rarely good for a person and immobility is a precipitating factor for delirium;

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);

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;

A protocol to address transitions of care to residential care (we have one — include link to our pdf);

A protocol to minimize use of physical restraints including use of trained companions/sitters;

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;

A protocol for post-discharge follow up (phone, telemedicine, other);

Use of volunteer engagement to enhance patient stimulation, mobility, companionship (we have the article from Stacy Stolarz);

Access to transportation services for return to residence (description of Home At Last);

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);

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?);

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)

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?)