Authors (including presenting author) :
Lui BKP(1),Ho SKS(1),Li HY(1),Lai TW(1),Wong JWL(2),Lai A(2),Yim B(3),
Lee H(4),Ngan C(5),Mak PKF(1),Kng PLC(1)
Affiliation :
(1)Department of Medicine and Geriatrics, (2)Physiotherapy Department, (3)Occupational Therapy Department, (4)Dietetic Department, (5)Speech Therapy Department
Introduction :
In our daily operation, nurses fill in many risks assessment forms upon patient admission. For frail elderly with multiple risks triggering multiple care plans, a geriatric care model is needed which systematically unifies these care plans. Our pilot care model in two acute geriatric wards uses a one page Integrated Geriatrics Evaluation & Management (GEM) Summary based on agreed protocols with the multi-disciplinary team along the patient journey without adding to paperwork
Objectives :
- To identify and integrate the risk profile of elderly in acute geriatric wards. - To collaborate with the multi-disciplinary team in acute geriatric care model - To facilitate communication of individualized care plan at clinical handover, at multidisciplinary case conference, at discharge and to families.
Methodology :
A Working Group involved inter-disciplinary members such as Doctors, Nurses, Physiotherapist, Occupational therapist, Dietitian, Speech therapist were formed since April 2017. Following team input, the roles for assessment and management was delineated. A one-page integrated summary to enable frontline nurses to communicate with the multidisciplinary team and at handover was piloted in two acute geriatric wards in July 2017. A risk profile of 50 patients was captured in December 2018 for analysis.
Result & Outcome :
The one-page summary with agreed assessment and risk managing interventions highlighted the priority patient care foci. Data for 50 consecutive patients provided a risk profile as detailed. 36% patient had cognitive impairment. 56% had high risk of fall. 50% patients had swallowing difficulty. 42% patients had high risk of developing pressure ulcer. 46% patients needed assistance in activities of daily living. Based on this, different care plans were executed. Such as, focused cognitive assessment “This is me” pamphlet; Therapeutic activities for patient with dementia have behavioral symptoms; Hydration round; Toilet round and Weekend exercises; Blanket referral for Physiotherapy for fall risk and Occupational therapy for patient for functional and cognitive decline. Besides, nurses would minimize the use of physical restraint on wandering patients by allowing relatives or carers to stay at bedside and offer flexible visiting hours. Early inter-disciplinary discharge planning engaging Medical Social Worker, Integrated Care & Discharge Support Team, Community Healthcare Service or End- of- Life Care Team After a trial run for one year, two compliance audits of the use of One Page Integrated Geriatrics Evaluation & Management Summary were done. The compliance rate rose from 70% to 90%. Conclusion: The geriatric multidisciplinary team could better identify, prioritize and formulate individual care plans with One Page Integrated Geriatrics Evaluation & Management Summary. Without adding more assessment tools but focusing on the delivery of an integrated care plan with multidisciplinary teamwork. It also helps communication with all parties, clinical handover and with families. Additionally, it is a training tool to enable junior nurses to navigate the complex but meaningful care of the elderly in a busy acute ward.
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