A train the trainer program aimed at GEDI staff education may need to include:
- Awareness of the specific risks associated with ED presentation for older persons;
- Attitudes to older people;
- Ability to assess and recognise geriatric syndromes, especially frailty; and
- Decision-making related to care of older persons in the ED.
Awareness of the specific risks associated with ED presentation for older persons
Nurses knowledge of issues relating to health risks for older persons presenting to the ED has been found to be poor (Deasey, Kable, & Jeong, 2014; Robinson & Mercer, 2007). Recognition of the differences in risk between age groups who present to the ED by GEDI/ED staff will provide evidence to underpin the GEDI model prioritising frail older persons in the ED. The literature reports older persons are at increased risk of adverse events related to presentation to the ED, prolonged length of stay in the ED (Ackroyd-Stolarz et al., 2011) and experience increased incidence of complications such as new pressure areas, delirium, infection and resulting functional decline (Dwyer et al., 2014). Adverse outcomes of ED presentation and hospital admission are found to increase length of stay in hospital, increase rates of representation and likelihood of increasing care requirements including RACF placement (Lafont, Gérard, Voisin, Pahor, & Vellas, 2011). See additional resources.
Attitudes to older people
ED staff work in a fast paced and high pressure environment focused on delivering emergency care to critically ill or injured people. Care of older people presenting in lower triage categories may not be seen as a priority for emergency care. Studies evaluating ED staff attitudes to older people suggest staff see them as dependent, with the ED not set up for the kind of multidisciplinary care they require which impacts negatively on ED workloads (Bulut, Yazici, Demircan, Keles, & Guler Demir, 2015). Skar, Bruce and Sheets (2015) reported staff seeing older people as coming to ED for the “One Stop Shop” of services it provides not available to them in the community. Interestingly, a systematic review of the literature reports that younger people are more likely to present to the ED for non-urgent visits than older people (Uscher-Pines, Pines, Kellermann, Gillen, & Mehrotra, 2013). Such negative attitudes by ED staff can impact of the care provided to this vulnerable cohort.
Validated instruments may be used to measure attitudes of ED nurses to older people such as the Older Person in Acute Care Survey (Deasey, Kable, & Jeong, 2016). A large survey of Australian ED nurses utilising this survey found that staff felt older people were more time consuming, needed family involvement in their care and found getting comprehensive history information difficult (Deasy et al., 2016). Similar findings were found in a Canadian ethnography highlighting ED staff distress when unable to meet the needs of the older person cohort (Kelley, Parke, Jokinen, Stones, & Renaud, 2011). Consideration of staff attitudes to the care of the older person in the ED need to be addressed for interventions such as GEDI, that are geriatric specific, are to be successfully implemented. Positive ways to do this may include:
- Assisting with improving general knowledge of ED staff to care needs of the older person
- Rotating interested primary nursing staff through the GEDI role when regular staff take leave
- Communicating the GEDI role focusing on how a GEDI model can assist the primary nurse to better care for their older patient to reduce complication and streamline their pathway through the ED.
Ability to assess and recognise geriatric syndromes and frailty
The presence of one or more geriatric syndrome should trigger a more detailed geriatric assessment is required either in the community, person’s own home or as an in-patient, according to the person’s needs (Cook, Oliver & Burns, 2012).
Examples of geriatric syndromes are:
- Falls
- Immobility
- Delirium and dementia
- Polypharmacy
- Incontinence
- End of life care.
To be able to do this effectively, skills are required such as:
- Cognitive assessment and delirium screening;
- Knowledge and understanding of geriatric syndromes and skills in recognition; and
- Pain assessment in the confused patient.
Care of the older person in emergency module
The
Identification of frailty
Knowledge of the specific needs of the older person presenting to the ED is critical to ensuring appropriate care is provided and risk of iatrogenic complications is minimised. The literature reports that frailty is distinctly different from ageing and the common age-related changes that develop overtime (Lekan, Wallace, McCoy, Hu, Silva & Whitson 2017).
The Frail Older Person’s Collaborative has endorsed a Queensland Health definition of frailty:
‘Frailty’ is a clinical term identifying a state of increased vulnerability, associated with but distinct from increasing age and multi-morbidity, resulting in disproportionate adverse health outcomes following a stressor’.
Clinical Frailty Scale
Queensland Health has endorsed the use of the
Emergency clinicians have an important role in recognising and screening for frailty and responding appropriately to enable effective emergency care. The CFS predicts adverse outcomes in older people in hospital, including iatrogenic complications, inpatient length of stay and death. Quantifying frailty through the CFS enables clinicians to streamline early appropriate referral for individuals identified as frail, which is an integral aspect of ED care planning. The scale enables clinicians to identify patients with a score between 4 – 9 or where clinical judgement suggests further assessment is required and refer the patient as per the Clinical pathway for screening and assessment of older persons presenting to the ED. This pathway is used by ED and GEDI clinicians and to target assessment and interventions to reduce risk for frail older persons, and by hospital flow co-ordinators to prioritise bed allocation pathways from the ED to the inpatient setting.
Early identification of the frail older person may enable identification of opportunities for hospital admission avoidance through linkage to appropriate community supports. In those requiring admission, it may improve access to timely admission and highlight the need for screening and preventative interventions to limit iatrogenic complications, reduce inpatient length of stay and improve patient outcomes.
Who requires a CFS?
The incidence of frailty increases with age, therefore it is recommended that people 75 years and over, or Aboriginal and Torres Strait Islander people aged 55 years and over be screened across the 24-hour spectrum. Clinical judgement should be applied to determine whether CFS should be performed on adults less than 75 years of age.
When and how should the CFS be performed?
The CFS is performed by any multidisciplinary ED clinician, often the primary ED nurse, during initial patient assessment, ideally within 30 minutes of presentation and after clinical stabilisation. The CFS is recorded on the relevant ED information system (EDIS or FirstNet).
The CFS is recorded on a scale from 1, or a ‘very fit’ person, to 9, representing a ‘terminally ill’ person. Each point on the CFS corresponds with a written description of health status along side a visual chart to assist with the classification determined by the clinician.
Frailty scoring may be undertaken in the initial instance from patient self-report and involves assessment of:
- Level of independence in relation to instrumental activities of daily living (managing finances, transportation, shopping and meal preparation, housework, managing medications) and activities of daily living (walking, feeding, dressing and grooming, toileting, bathing and transferring) immediately prior to current acute illness.
- Presence of terminal illness
- Presence of dementia and degree of associated cognitive impairment.
The CFS should be recorded in the clinical record and it should prompt a referral to the GEDI service should the patient score between 4 to 9.
Decision-making related to care of older persons in the ED
The GEDI nurse focuses on influencing decision making in relation to disposition of the older patient in the ED. This aims to provide information and options for the medical team that advocate for the patient and consider the patient and families wishes.
For the other staff in the ED, education can be provided by the clinical coaches to influence knowledge and skills in the care of the older person. Prompting ED staff can be useful in increasing awareness of the needs of the older person.
Some examples are:
- “This person appears confused. Have you considered a 4AT assessment?”
- “Have you assessed pain in this patient who appears confused? Try using the PAINAD scale – the Pain Assessment in Advanced Dementia Scale” (Warden, Hurley & Volicer 2003).
- In the case of the dying patient - “Have you assessed the patient for a palliative pathway? Have you considered accessing a pump for appropriate pain medication delivery?”
Simple prompting such as this increases awareness of geriatric syndromes and specific needs in the care of the older person.
