Transforming emergency care for older adults: GEM program in Queen Elizabeth Hospital

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Authors (including presenting author) :
Chan MY (1) Lee YF (1),Tam MY (1), Fong KH (1),Hung YK Shirley (2), Ngai SC Jenny (2), Wong Agnes (3), Tam Grace (3), Wong Gordon (3)
Affiliation :
(1) Pre-Discharge Service, Queen Elizabeth Hospital (2) Nursing Services Division, Queen Elizabeth Hospital (3) Emergency Department, Queen Elizabeth Hospital
Introduction :
In Hong Kong, the population of aged ≥65 years will increase from 1.16 million in 2016 to 2.37 million in 2036. Older people were the largest group of health care service consumers. The frequency of emergency admission is high and the length of stay (LOS) was longer for older patients. Queen Elizabeth Hospital (QEH) is a major acute hospital in the Kowloon Central Cluster of Hong Kong. In the period of Jan – Nov 2018, total 38% of 1st AED attendance were aged ≥ 65 years . And their average length of stay was 5.8 days in acute medical units. Atypical presentation of disease, covered on complex medical and psychosocial comorbidities create pressure to existing ED system. Subsequently, it incurred risks of adverse events, e.g. general de‐conditioning and functional decline, to older adults. In order to uphold the quality of care to the older adults, a Geriatric Emergency Management (GEM) program is launched in Emergency department and 2 EM Wards to support the care delivery process with the aim to ensure safe discharge and avoid unplanned readmission. It is an evidence based acute care delivery model (Napire & MacLeod, 2009) for managing high risk seniors and rationalizing complex discharge planning needs incurring by the aging population. In addition, this program helps to build capacity through knowledge transfer among ED staff and other health care partners.
Objectives :
1. Proactive screening and planning discharge upon admission for older adults in AED and EMWs department 2. Identification of clinical, functional, social issues and other risk issues 3. Link up to geriatric care, primary care and /or community services 4. Reduce length of stay, protect patients from the risk of hospital acquired infections and /or complication. 5. Improve patient experience during their stay in hospital. 6. Prevent avoidable re-admission
Methodology :
The prospective study was conducted between April to Nov 2018 for a patient who was aged ≧60 years, suffering from one of the medical illness such as1) increasing fall with balanced deficiency; 2) Dementia; 3) Low back pain (LBP) or Joint / knee pain; 4) Decrease General Condition and 5) Dizziness. However, those with unstable hemodynamics, medical emergencies, or social needs alone such as placement problem were excluded. The care team involves EM doctor for medical treatments; GEM nurses and Allied health professionals provided proactive Comprehensive Geriatric Assessment (CGA) & appropriate interventions, engaging patient on disease management & discharge planning, coordinated appropriate interventions to ensure patients can be treated and safely discharged to the community with adequate community support.
Result & Outcome :
A total 278 patients with mean age 78.6 were recruited in this GEM program from April to Nov 2018). Their average length of hospital stay was 1 to 2 days. The functional status of patients could be maintained without further deterioration. Total 150 recruited patients were direct home with appropriate community support provided. The unplanned readmission rate within 28 days was 4.3% which was lower than general AED & EM cases. Furthermore, 74.8% of patients bypass acute Medical or other acute wards admission. With total 1317 acute medical bed days saved. Moreover, GEM nurse have fulfill the system focused roles on capacity building by sharing sessions to increase the awareness and knowledge to better manager geriatric issues in ED.

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