Implementing an Observation Unit Model in the Geriatric ED

Main Learning Points

Dr. Stephen Meldon @ 8:42

At the Cleveland Clinic they have adopted a model where older patients can stay in their 4-bed Observation Unit for up to 23 hours. Their care is managed by either a geriatrician or a geriatrics Advanced Practice Nurse who can also provide consults in the ED for patients likely to be discharged directly from the ED. Their patient selection is a home-grown model of: >65 with cognitive impairment; or >65 with two of the following; or >80 with one of the following: polypharmacy, frequent falls; multiple ED visits; dementia. He outlined their carefully considered workflow and described some clinical scenarios demonstrating admission avoidance and better patient outcomes. Their published data demonstrates a 20% absolute drop in geriatric admissions. He reviewed their keys to success – patient selection, implementation of a comprehensive geriatric assessment using a team approach, and attention to transitions of care.

Dr. Simon Conroy @ 22:32

At the University of Leicester they have a model that uses close collaboration between a geriatrician and the ED clinician which originally focussed on older fallers where ED docs addressed the injuries and geriatricians address the illness that cause the fall.  This model led to a significant increase in ED discharges, AND a significant decrease in 7-, 30-, and 90-day readmits.  The original 16-bed Emergency Frailty Unit has now more often been filled with short-term admits.  And the Acute Frailty Team  — frailty nurse, PT, OT, Pharmacist, Geriatrician – now does more in-reach into the ED with the goal of decreasing admissions for falls, delirium end-of-life care and injuries.

Dr. Lauren Southerland @ 36:56

Dr. Southerland reviewed many of the financial considerations of implementing an Observation Unit, including the importance of getting all financial stakeholders in line with the concept.  She also addressed – and dispelled – the common misconception that admission to an Obs Unit will cost the patient more than admission to hospital.

Details

Goals

1. To explore strategies to extend the assessment of complex older patients using an observation unit model in the Geriatric ED;
2. To consider funding models and approaches to financing an observation unit approach;
3. To hear first-hand experiences from various international sites about the function of their observation units, frailty units, clinical decision units, etc.;
4. To provide resources – workflows, job descriptions, assessment tools – that may help you start an observation unit.

Expert Panel

Simon Conroy, MD
Professor of Geriatric Medicine
University of Leicester

Stephen Meldon, MD
Senior Vice Chair; Institute Patient Experience Officer
Emergency Services Institute at Cleveland Clinic Academic Chair, Department of Emergency Medicine,
Cleveland Clinic Lerner College of Medicine of CWRU

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

Jay Banerjee, MD
Emergency Physician
University of Leicester, United Kingdom

Moderated By

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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