Practical Steps to Prepare your Hospital for Geriatric

Practical Steps to Prepare your Hospital for Geriatric Emergency Department Accreditation Don Melady November 10 2017 SREMI Schwartz/Reisman Emergency Medicine Institute

Disclosures: Conflicts of Interest • As part of the Geriatric ED Collaborative, I am financially supported by grant funding from the West Health Foundation and from the John A. Hartford Foundation to promote improved care of older adults in EDs • I am a member of the Board of Governors of ACEP’s Geriatric ED Accreditation Process. ACEP charges a fee for accreditation 2 SREMI

Goals of this presentation 1. To introduce a (non-ED) audience to efforts to improve care of older people in EDs 1. To describe the process for accreditation of older person-friendly EDs initiated by the American College of Emergency Physicians 1. To suggest strategies that you can use at your site to participate in this accreditation process 3 SREMI

4 ED in the intersection of care of older people Self-Referral, from community Physician Office Urgent Care or Walk-in Clinic 4 Self-Referral, Emergency Medical Services Emergency Department Hospital Nursing Home or Assisted Living SREMI

• Paradigm shift of ED physical design and care (Pediatric, Psych EDs) • Geriatric ED Interventions (GEDIs) • No “Geriatric EDs” or “Senior EDs” at time of press: 2007 5 SREMI

Geriatric ED Guidelines Staffing Education Processes of care Transitions of Care Quality Improvement Physical environment 6 2013

Geriatric Emergency Department (GED) Collaborative 1. Build the collaborative 2. Build the evidence of GED impact 3. Develop data infrastructure 4. Plan for sustainability 5. Build partnerships 7 2014 -2017 SREMI

Geriatric Emergency Department (GED) Collaborative 1. Aurora Health Care (3 hospitals), WI 2. 3. 4. 5. 6. 7. 8. 9. 8 Magee Women’s Hospital, Pittsburgh, PA Mount Sinai Medical Center, New York NY St. Joseph’s Regional Medical Center, NJ Northwestern Hospital, Chicago, IL University of North Carolina, Chapel Hill, NC University of California, San Diego, CA University of Chicago, IL Emory University, Atlanta, GA 2014 -2017 SREMI

How do we know who is providing good ED care? How can we promote good ED care? How can we ensure good ED care? 9 SREMI

American College of Emergency Physicians Geriatric ED Accreditation 10 To ensure that a Geriatric ED is an ED verified by a trusted agent that meets the needs of older adults SREMI

Three Levels All levels promote improvements in: Staffing Education Processes of care Transitions of Care Quality Improvement Physical environment 11 SREMI

Three Levels Level 3 Good older adult ED care achievable by any ED Level 2 Extensive enhancements of $5, 000 older adult ED care requiring focussed commitment Level 1 12 $1, 000 Excellent and uniform $10, 000 older adult ED care requiring whole system enhancements and commitment SREMI

Level 3 1. One MD with some focussed education in geriatric Emergency Medicine 2. One RN with some focussed education in geriatric ED nursing care 3. One initiative that focussed on care of older ED patients (e. g. , a catheter utilization policy, a functional assessment tool, a process for transitions of care) 4. Access to mobility aids and food and drink 13 SREMI

Level 2 Staffing 1. A physician champion or medical director 2. A geriatric nurse case manager for at least 56 hours/week 3. Access to 2 members of an interdisciplinary team (PT/OT/SW/Pharm) 4. Executive level supervision 14 SREMI

Level 2 Education 1. Focussed education of all staff MDs in domains of geriatric EM 2. Focussed education of all staff RNs in geriatric ED nursing 15 SREMI

Level 2 Policies and Procedures (10 out of 27 options) 1. Screening process for delirium; for dementia; 2. Standardized assessment of function; of fall presentations; of suspected abuse; of medication use 3. Order sets for pain management; for common presentations; for avoiding PIMs; to promote mobility 16 SREMI

Level 2 Policies and Procedures (10 out of 27 options) 4. Access to palliative care consultation; geriatric psychiatry; to rehabilitation beds; to mobility aids; to food and drink; to volunteer support (e. g. HELP); 5. Standardized approach to discharge planning to the community; to long-term care; to notification of other care providers (PCP, specialists); 6. Standardized access to post-discharge community paramedicine; to phone follow up 17 SREMI

Level 2 Quality Improvement and Outcome metrics 1. Evidence (e. g. chart audit) of 75% adherence to the policies and procedures 2. Tracking of outcome measures in at least 3 domains (e. g. positive screens, referrals made, LOS, repeat visits, mortality, discharge destination, others) 18 SREMI

Level 2 Equipment and supplies 1. Walkers and canes 2. 3 out of: non-slip socks; hearing assists; blanket warmer; low beds; appropriate mattresses/pillows; commodes; condom catheters; 19 SREMI

Level 2 Physical environment 1. Required: Two chairs per patient bed; clock in each room; food and drink 2. Recommended: optimal lighting; noise reduction; non-slip floors; hand rails; signage and way-finding; accessible toilets; raised toilet seats 20 SREMI

Level 1 More of all those criteria! Staffing: larger interdisciplinary team; patient advisor Education: same Policies and Procedures: 20 out of 27; criteria for access to the GED pathway QI: same; Outcome measures: 6 Physical environment and supplies: same 21 SREMI

Geriatric ED Accreditation 22 To ensure that a Geriatric ED is an ED verified by a trusted agent that meets the needs of older adults SREMI

www. geriatric-ED. com 23 (Search: checklist)

24 www. geri-EM. com

Motivation to become an accredited Geriatric ED? • • • 25 Improved outcomes Quality assurance Standardization of processes Reputation enhancement Potential return on investment SREMI

Thanks To West Health and the John A. Hartford Foundation To the American College of Emergency Physicians and members of the Geri ED Accreditation project To members of the Geriatric ED Collaborative: – – – 26 Kevin Biese Chris Carpenter Tess Hogan Ula Hwang Michael Malone Don Melady SREMI

Questions? don. melady@utoronto. ca www. geriatric-ED. com www. geri-EM. com @geri_EM #Geri. ED 27 SREMI