Best Practices in COVID Care in the Geriatric ED

Main Learning Points

Dr. James Kenny @ 6:40

James described how the ED-based telehealth program at New York-Presbyterian pivoted to include the assessment of older people – often quite isolated – who either had or were worried they had COVID.  It allowed them to make real-time decisions about who needed to be seen urgently in their ED, who needed to be followed in their homes, and who could be reassured, thus saving avoidable ED visits.   He also discussed some of the learning points for both ED providers and for patients to make this system work.  He emphasized that for people older than 80, often some additional tech support is required.

Dr. Maura Kennedy @ 17:40

Maura reminded the audience that delirium, always an important consideration for older ED patients, is particularly so during COVID:  delirium is a common, underrecognized presenting symptom of COVID (28%);   and incident delirium (that which develops during the ED stay) is particularly challenging because of the many challenges that our PPE-laden and infection-control EDs present to older people. Top symptoms:​  Fever present only in 56%​; Cough and SOB in 50%​; 40% with hypoxia​;  Delirium was the sixth most common symptom present in 28%.

She outlined some strategies and tools they’ve used at her Harvard hospital to both prevent and decrease the symptoms of delirium, such as a comfort cart and hearing assists.    She recommends the Delirium Triage Screen and the b-CAM as helpful screening tools.

Dr. Kevin Biese @ 26:00

Kevin discussed the essential role that family and other caregivers play in the ED management of older people especially those with cognitive impairment.  He gave us some valuable advocacy points to take to decision-makers at our sites:  “Caregivers” are not “visitors.”  People who know the patient well and, often, are required for the day-to-day activities of the patient can add a lot to their care in the ED too – and take a load off ED staff.  Some resources are in the chat box.

https://blog.aarp.org/thinking-policy/alone-and-confused-the-effects-of-visitor-restrictions- on-older-patients-and-families

Dr. Kevin Munjal @ 34:10

Kevin introduced the audience to the field of Community Paramedicine,  a broad term to describe engaging the personnel of EMS – paramedics, EMTs, ambulance attendants – in a wider role for community-based care than simply stabilizing and transferring of patients to hospitals.  Older adults can benefit by getting more patient-centred care in their home, possibly using telehealth,  rather than just being taken out of their home.  It can also be used for scheduled proactive care in the home provided by paramedics, particularly after discharge from ED, instead of just reacting to an emergency when the discharge plan goes wrong.  This could include something called “Transport Plus” where an ambulance is engaged to transfer the patient back to their home and to ensure the discharge plan is understood and implemented and do a fall risk assessment of the home.

Details

Goals

• To give practical guidance to improve care of older patients with COVID.
• To share learning from around North America that has made a difference during the first waves of COVID-19.
• To identify resources and strategies to:
  • implement telehealth,
  • enhance visitor policies,
  • improve delirium identification and assessment,
  • improve goals of care discussions, and
  • enhance transitions of care.

Expert Panel

James Kenny, MD
Assistant Medical Director,
Milstein Adult Emergency Department
Medical Director,
NYP-Columbia Geriatric Emergency Department

Maura Kennedy, MD
Director Geriatric Emergency Medicine
Massachusetts General Hospital

Kevin Biese, MD, MAT
Associate Professor, Emergency Medicine
Vice-Chair of Academic Affairs
Associate Professor, Division of Geriatric Medicine
Co-Director, Division of Geriatric Emergency Medicine
University of North Carolina School of Medicine

Kevin G. Munjal, MD, MPH, MSCR
Associate Professor, Emergency Medicine / Population Health
Medical Director, Community Paramedicine
Icahn School of Medicine at Mount Sinai New York

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.

Geri-EM.com Geriatric-ED.com Publications