Authors (including presenting author) :
Cheng PPP(1), Mo KKL(2), Ngan HK(3), Wong SY(3)
Affiliation :
(1) Central Nursing Division, Yan Chai Hospital, (2) Department of Medicine, Yan Chai Hospital, (3) Department of Accident & Emergency, Yan Chai Hospital
Introduction :
In winter surge, nearly all hospitals would simultaneously face the overwhelming challenge of emergency visit by older adults. The condition was described as a sentinel event signifying the impending breakdown of the health care system. Overseas studies reported both hospitalization and unsupported discharges from the Accident & Emergency Department(A&E) would carry significant risks for older adults, including iatrogenic complications, functional and cognitive decline, and loss of independence. It creates a great dilemma for the A&E doctors on discharging with or without referral and admitting older adults with chronic medical problems. An extension of Geriatric Service Model “Liaison Service @ Front Door” is developed with full support from Geriatric Team, A&E and Community Nursing Service (CNS) for selected A&E elderly patients as well as patient at Emergency Medical Ward (EMW) of Yan Chai Hospital since December 2017.
Objectives :
1. To improve liaison service between A&E, EMW and Medical service in hospital 2. To minimize unnecessary hospitalization by providing early referral to Geriatric evaluation & management at Fast Track Clinic 3. To better utilization of hospital resources and community social support services.
Methodology :
Patient aged > 65 of Category 3 and 4 in A&E, or in-patient at EMW with low medical acuity initially planned for hospitalization or unsafe discharged were selected by A&E senior doctor for referral to experienced geriatric nurse for comprehensive geriatric assessment. The initial care plan with a standard form based on frailty assessment tool (Clinical Frailty Scale) and Abbreviated Mental Test was formulated. Subject to the individualized problems, a conjoint care plan was developed to facilitate a range of community and ambulatory resources tailored for individual needs, including Community Nursing (CNS) & Community Geriatrics Assessment Service (CGAS), Geriatric Day Hospital (GDH), Fast Track Clinic, Integrated Care and Discharge Support (ICDS) arrangement.
Result & Outcome :
47 patients were recruited from Dec. 2017 to April 2018 with 20 (42.6%) female with average 80.4 years (range 74 to 93); 27(57.4%) male with average 83.7 years (range 72 – 101). 33 patients were screened at A&E whereas 14 patients were referred from EMW. 80.9% (38) of them were in community dwelling. 44.7% were either living alone or daytime alone without adequate social support. Among 34 (72.3%) of them were being classified as frail or vulnerable. Top reasons for attending A&E were fall incident (14%) and complaint of dizziness (10.6%). After thorough assessment, health education and nursing interventions, 30 (63.8%) patients were discharged with community support based on frailty needs assessment; 45.5% were discharged with Fast Track Clinic (FTC)/CGAT support or physical workup at GDH. 14 cases (42.4%) were unavoidable to have hospital admission. 4 (12.1%) patients were intentionally admitted to Emergency Medical ward (EMW) for ICDS referrals for logistic reason. Among those patients after the captioned liaison service, 22/33 (66.7%) were successfully discharged without A&E re-attendance and/or re-admission within 28 days. The “Liaison Service @ front door” is enacted by both skillful case selection from AED doctors and quick frailty assessment accompanying with coordinated community & ambulatory services. It provides safe discharges for frail elders with options of care.
Co-location with:
