Geriatric Emergency Medicine Special Interest Group
Newsletter July 2021

Dr Carolyn Hullick | Chair

Welcome to our first Geriatric Emergency Medicine Special Interest Group Newsletter. A special thanks to Rosa for bringing it all together as well as the many people who have contributed. A lot is happening in Geriatric Emergency Medicine and we are keen to hear from anyone who would like to write a piece. I am particularly interested in how you care for older people in your own countries. In many ways, we have similar pressures but a large variation in cultural expectation, funding and models of care. Your stories are important, so send them in! COVID has been particularly devastating to our older person population. Our heart goes out to many countries that have struggled to provide healthcare for this vulnerable population.

In June the virtual ICEM21 was held. Sadly, it could not be face to face but this did bring some advantages too. Our Geriatric Emergency Medicine track had four phenomenal speakers from across the globe who would all not have been able to present if it was not a virtual event. Dr Jay Benerjee spoke on the importance of incorporating frailty assessment into Emergency Department practice. Recognizing that someone has frailty allows care to be tailored to their needs and goals of care, care that is patient centred and about what is important to them. Dr Maaret Castren spoke about the challenges of interpreting vital signs on older people. Interestingly respiratory rate is a vital sign that seems to be most undervalued. It can be an important marker that the person is deteriorating. Next up was Dr Shan Liu who challenged us all to consider how we not only look for the cause and consequence of a fall in an older person but how we can build prevention pathways into our practice. The message I took away was recognizing the many hospital and community partners who support older people and how do we harness them for our own ED patients. Last was Dr Christian Nickel who spoke on the high risk ED presentation, abdominal pain in older people. He outlined the life threatening diagnoses that can be missed and encouraged us to think about using imaging more often in our practice. Thanks for a great session and also thanks to Dr Nemat AlSaba who provided excellent moderator support. It was also our first virtual marketplace. The marketplace has been a GEMSIG ICEM favourite for the last few years. It provides high energy interactive education with lots of socialising and fun. There was some really positive things about the marketplace and we have lots of lessons that we will be able to incorporate into next year’s marketplace. ICEM 2022 is in Melbourne and I suspect it will be a hybrid event. Planning is underway.

I look forward to seeing many of you at our next virtual meeting and thanks for all the work that you do in caring for older people

Carolyn

Value-based care of older people

Maaret Castrén, Lauri Mäki
Finland

Long-term residential care facility (LTRCF) residents are often transferred to emergency departments due to relatively minor health problems that could be treated in the facility. These transfers are burdensome for the residents and often lead to adverse effects. Older adults living in nursing homes or receiving long-term home care are in higher risk of losing their daily functional capacities or dying after hospital care compared to independently living older adults. Emergency department (ED) visits have been linked to delirium, hospital-related infections, medication errors and information errors. Besides patient-related harms, ED visits and especially hospitalizations cause waste in terms of overproduction – unplanned transfers reserve beds in nursing homes and hospitals. Relatives/proxies tolerance for the patient not going to ED was lower than personnels and patients.

LiiSa (an acute outreach service unit “mobile hospital”, in Finnish, liikkuva sairaala, hence the acronym LiiSa)  is a new operator providing acute care for long-term residential care facility residents, treating non-life-threatening exacerbations of chronic illnesses and new injuries or illnesses of the residents on site, instead of transferring them to the ED. LiiSa started operating in March 2019. It operates among 40 public long-term residential care facilities with 1366 residents in Espoo and Kauniainen, two cities with a total of about 300,000 inhabitants.

The Fiona Stanley Hospital Emergency Department Falls Pathway (Perth, Australia)

Our ED Falls Leadership Team (centre). A/Prof Glenn Arendts (Medical), Ms Sandra Dumas (Physiotherapy) and Ms Naomi Leyte (Nursing) flanked by Ms Chloe Macri (‘Stay on Your Feet’ Program) and Mr Paul Artis (Orthogeriatics Unit Nurse Manager)

Glenn Arendts, Australia

Older patients presenting to ED after a fall are often seen as trivial and given lower priority unless seriously injured. There is typically no systematic approach to identifying falls risk factors and no formal focus on secondary falls prevention.

Since 2017 we have implemented, evaluated and embedded into practice a system to support older people who fall and present to our ED, by providing timely best practice multidisciplinary assessment, fast track access to specialist aged care assessment within the ED, intensely focused hospital admission avoidance, falls prevention and, when needed, direct admission to an Aged Care Evaluation (ACE) unit. The key features include direct admission to an ED Short Stay Unit, standardized assessment of cognition, medications, mobility and discharge risk, and access to a geriatric consultation service for complex patients. We currently manage approximately 3000 patients aged 65+ years per annum through our pathway. The program supports an ED trainee to receive 12 months of geriatric emergency medicine special skills training.

Full results have been published at Australian Health Review 44(4):576-581. In summary we have halved ED length of stay, increased discharge home from ED by 20%, halved hospital bed day usage for falls patients and reduced readmission rates, all by an intense focus on giving falls the priority they deserve. We welcome the opportunity to share our pathway and lessons learnt with other EDs worldwide. Please email glenn.arendts@uwa.edu.au

Developing a Provincial Emergency Department Delirium Pathway

Britanny Ellis, Canada

Delirium is a commonly missed diagnosis in emergency departments throughout the world, and this is associated with poor patient outcomes, and increased healthcare costs. Studies around the world have consistently demonstrated that a large number (roughly 70-80%) of delirium cases are missed in the ED, and that over 90% of these missed cases are subsequently missed on inpatient units (Han et al, 2009). Hypoactive delirium is more common, and more frequently missed in the ED. Older people are at increased risk of presenting with delirium, as well as developing delirium throughout their ED and inpatient stay.  Fortunately, delirium screening and assessment tools exist which are rapid to perform and, when combined, are very sensitive and specific for detecting delirium.

With this in mind, we developed an ED Delirium Pathway to help enhance recognition and care of adults with delirium in emergency departments across the province of Saskatchewan, Canada. Saskatchewan is one of thirteen provinces and territories in Canada, with a populous of 1.2 million people spread over 650,000 km2 (larger than the entirety of France). There are two large urban centres (~250 000), three medium urban centres (30-40,000) and seven small urban centres (10 – 30,000), with the remainder of the population living in mixed rural and remote communities.

This ED delirium pathway is anticipated to be the first of a series of delirium works spanning the ED, inpatient care and possibly beyond (e.g. long term care). The team aims to create a unified and cohesive pathway surrounding prevention, diagnosis and care for patients with delirium. The focus is on delirium prevention, as well as improving non-pharmacologic care of patients with delirium, as well as improved decision making surrounding pharmacologic intervention when required. It is also anticipated that future care pathways and innovations will be developed regarding core geriatric concerns and presentations to the emergency department.

The use of screening tools in Emergency Medical Services on the identification of patients with nutritional risk, risk of falls, and potential cognitive impairment

Maaret Castrén, Eeva Saario, Marja Mäkinen
Finland

Inadequate nutrition, falls, cognitive impairment and delirium are common problems among acutely ill older people and are associated with complicated and prolonged health problems and mortality. Early recognition of nutritional risk, risk of falling, and cognitive impairment could help improve the outcomes. Emergency departments (ED) are crowded, and lack of time and resources hinders risk assessment. Emergency medical services (EMS) have been seen mainly as a party to treat and transfer acutely ill patients to the ED and have traditionally not been utilized in preventive health care. EMS meet patients at their homes and have an opportunity to assess the patients’ coping at home and could adapt a bigger role in being part of preventive health care.

A set of validated electronic screening tools with some modifications to make them more suitable for EMS was used to identify patients at nutritional risk, risk of falling and having cognitive impairment. The risk assessment was performed in the ambulance during transfer in all community-dwelling patients over the age of 70 requiring non-urgent ambulance transfer to the ED and who could be interviewed. The EMS staff were instructed to report to the ED staff on a patient with a positive result in any of the screenings. In a pilot study a total of 488 were screened. Over half of the patients were found to be in at least one risk group. The results have been submitted to a journal.

We think that risk assessment should become a regular intervention in the EMS, and it might be beneficial to perform risk assessment on older non-transferred patients as well. By providing an accurate description of the patient’s pre-hospital condition, the EMS staff can alleviate the workload in the ED in order for the ED staff to make objective and right treatment decisions and to recognize and react to alterations in the patient’s status.

ED physician-based nursing home assistance

Claus-Henrik Rasmussen, Nina Andersen, Søren Mikkelsen, Mikkel Brabrand, Annmarie Lassen
Denmark

As an alternative to ambulance transport to the Emergency Department (ED) and in-hospital evaluation and treatment, we thought it would be possible to conduct acute evaluation and treatment on site in the nursing home.  In our service model this is completed by a trained emergency physician from the local ED in collaboration with a highly qualified acute nurse team from the local municipality, and can provide an alternative to hospitalization.

On weekdays between 8.00 and 16.00 all emergency ambulance activations involving nursing home residents in the Odense Municipality, simultaneously activate a request to attend by a senior doctor in the ED Odense University Hospital and the municipality acute nursing team.

The ED doctor evaluates the patient (and can complete point of care blood testing and ultrasound as well as physical examination).  They then start treatment, including fluid and antibiotic if needed, in collaboration with the professional team (ambulance personnel, municipality acute nurses and nursing home personnel) as well as with the patients and relatives. The patient can remain in their nursing home or can be transported to hospital depending on what best suits the patients goals of care.

In our area, the Odense Municipality we have 24 nursing homes with 1284 residents. Between 1st of December 2020 and 9th of April 2021, we completed 251 contacts, corresponding to 2.6/day on weekdays and 5/100 nursing home residents per month. Among all patients 169 (67%) had POCT analysis performed, 179(69%) acute ultrasound, 223 (92%) of all patients were treated in the nursing home and did not immediate need for hospitalization. The one-month hospitalization rate was 16%, one-month mortality was 32%.

We feel that an ED physician-based service for acute sick nursing home residences can provide onsite acute evaluation and treatment for over 90% of the acutely ill nursing home patients who otherwise would have been transported to the hospital and treated there. This project successfully demonstrates that it is possible to move the expertise of the ED to vulnerable nursing home residents.

Pathfinder

Paul Maloney, Ireland

Traditionally, in the Republic of Ireland (ROI), all patients are brought to the Emergency Department (ED) following an Emergency Medical Services (EMS) call, unless they decline to travel. The EMS call is activated by dialing 999/112. The increase in older people with complex multi-morbidity has been identified as a key driver to ED crowding. Older people are particularly vulnerable to adverse events associated with ED presentation, such as functional decline(1), infections(2), falls(2), medication errors(2), pressure ulcers(2-4), and delirium(2,5). Alternative care pathway models can improve outcomes for older people and reduce ED crowding.

Pathfinder is a collaborative project between the National Ambulance Service (NAS) and the Occupational Therapy and Physiotherapy Departments at Beaumont Hospital, North Dublin, ROI.  The service was first trialed in 2019 and subsequently received funding from the Government of ROI Slaintecare Integration Fund for a 12 month pilot in 2020 (Grant Agreement No. 392). The service aims to minimize unnecessary ED attendances for people greater than 65 years, through the utilization of a range of alternative care pathways following an EMS call.

The Pathfinder team is activated by the National Emergency Operations Centre and only responds to EMS calls. The team accepts direct EMS calls within an agreed low-acuity code set (falls, non-traumatic back pain, generally unwell, blocked/dislodged urinary catheter) or crew referrals from any NAS or Dublin Fire Brigade crew, irrespective of initial dispatch code. The Pathfinder team operates a ‘Rapid Response Team’ (Advanced Paramedic and Physiotherapist or Occupational Therapist) (8:00-20:00, Monday-Friday) and a ‘Follow-Up Team’ (Physiotherapy and Occupational Therapy) (8:00-16:00, Monday-Friday).

Next GEMSIG Meeting 5 August 2021
8am Toronto, 10pm Melbourne, 1pm Dublin

It's impossible to arrange an international meeting that suits everyone so we apologize in advance if this doesn't suit. 

This meeting will be held via Zoom.

If you're planning on attending please let Brittany Ellis know so that she can keep track of attendees: Brittany.Ellis@saskhealthauthority.ca

International twitter account

Drs Danya Khouja and Lauren Sutherland have started an international twitter account @EMgeripearls Different countries and people will run the account for a month. IFEM GEMSIG have been allocated January, ably managed by Dr Rosa McNamara and Dr Don Melady. Its aiming to spread international GEM resources, education, events, tips. If you are keen to be involved, let Dr Nemat AlSaba or Dr Rosa McNamara know. Please follow and contribute. It’s fun as well as a good chance to spread the GEM word!

iEM education project

iEM Education Project will be working on EM Clerkship Book 2022 Edition and iEM Live Sessions for the second part of the year and the first quarter of 2022. We have new chapters and looking forward to having IFEM members involvement with their trainees in these two initiatives for upcoming months and years. We are going to reach members, committees, and SIGs for these activities soon. Please visit the https://iem-student.org website and Twitter https://twitter.com/iem_student

COVID-19 Survey

It has been a challenging 18 months with COVID having devastating impact on all our communities around the world, particularly older people. Dr Shan Liu, her geriatric emergency medicine fellow from Thailand, Dr Thiti Wongtangman and a group of international GEM researchers are keen to understand  how different countries have been impacted by and managed COVID in older people. We encourage you all to take part in  this important survey. Its important that we learn the lessons of the pandemic and think about systems that need to be in place for future pandemics. 

Notice To Survey Participants regarding personal data processing activities document.

Shan can be contacted on Email: sliu1@mgh.harvard.edu and telephone 617-726-4809. You should have received a link to the survey already. If you haven’t, contact Shan or Thiti directly,  twongtangman@mgh.harvard.edu

IFEM Feedback Survey

It’s really important to us here at IFEM to make sure we’re providing value to our Members, Volunteers and Emergency Medical Care Workers around the world.

We’d like your feedback how we’re doing in achieving our mission and objectives, the value we’re providing, and to learn how we can advance our goal of improving emergency medical care across the world.

We are also about to re-develop our website, and would like to learn about your experience and thoughts of our current website to ensure our new website provides enhanced value, is easy to use and contains the information and resources you need.

This survey will take you approximately 15 minutes and the responses are anonymous.

The survey is available in four languages – English, Spanish, Portuguese and French

We really appreciate you taking the time to complete the survey, and for everything you do to improve emergency medical care.

Survey closes 20 August 2021.

Play a role in the design of the new IFEM website – take part in a focus group

The IFEM website plays an important role in providing valuable and relevant information and resources to its Members, Volunteers and emergency medical care workers around the world.

IFEM is about to commence a website redevelopment project. To gain insights into what our website users need from our website, and to better understand how our website can serve you through content and structure, IFEM are holding two focus groups.

These fun and interactive focus groups will enable you to play an important role in designing the new website and will include:

• Persona building exercises
• SWOT analysis of the current website
• Online card sorting activities allowing you to build your ideal IFEM website and discuss with the group.

IFEM are running two focus groups via Zoom, with ideally around 7 people per workshop that represent a cross section of our website users – country, gender, resource setting.

To be part of the focus group you'll need to be at your computer/laptop with internet access.

Focus Group Dates
11am - 1pm Tuesday 17 August 2021 UTC
9pm - 11pm Wednesday 18 August 2021 UTC

Unsure of what time this is in your time zone? Use Savvy Time Converter

To take part in a focus group please complete the application form on the website.