Different models of providing enhanced care of older persons in the ED exist. The GEDI model situates the team within the ED management structure. This is considered important because the focus of the service is not just discharge or admission but rather the enhancement of person-centred care within the ED and streamlining of service delivery.
During the GEDI evaluative research project this emerged as a core issue. Suggestions for addressing this include ensuring that the staffing, financial management etc. of GEDI service remains within the ED organisational structure and that the GEDI team report to ED management rather than any other hospital and health service entity outside of the ED. A similar model exists in general EDs that also accept paediatric presentations. The paediatric ED specialist staff are acknowledged as clinical experts but the responsibility for managing this cohort of patients is shared by all staff and the responsibility for service provision resides with ED management group.
As the local demographic and clinical needs of the community served by the ED change, ED management, working with the GEDI team, need to ensure the appropriate development of the GEDI service. This may mean that staffing levels will change and even the specific expertise within the team may need to be reviewed from time to time. This process is enhanced by having a robust monitoring and evaluation framework in place.
Monitoring and evaluation of the care of the geriatric patient in the ED
In addition to evaluating the effect of the GEDI service on patient outcomes (discussed in detail in part 4) the GEDI team can contribute to the monitoring and evaluation of the quality of care for older persons in the ED. In general, it is suggested that evidence-based practice guidelines are used to direct the care for older persons in the ED (see: The Silver Book (Cook et al., 2012)). However, implementation of evidence-based practice guidelines are less effective than well-targeted indicators for differentiating the quality of care between hospitals (Schnikter, Martin-Khan, Burkett, Brand, Beattie, Jones, …Emergency Care Panel, 2015). Consequently, EDs may choose to audit specific care processes to monitor the quality of care provided to this cohort. GEDI team members may be able to assist in this process. Audits that may be conducted to evaluate care include:
- Review of all level 1 and 2 RISKMAN reports for all patients over the age of 70 years in the ED
- Review of all RISKMAN reports for falls in the ED, in patients over the age of 70 years
- Numbers pf patient seen by the GEDI team compared to numbers referred
- Timeliness of regular prescribed medication in the ED
- Provision of appropriate food and fluids during the diagnostic and treatment process
- Appropriate pain assessment and management
- Appropriate use of intermittent, in-dwelling urinary catheters and intravenous canula devices
- Delirium screening for older persons presenting with behavioural management issues or developing behavioural management issues during ED stay
- Communication with GP, RACF, family, carers.
Further monitoring and evaluation
Presenting process and outcome measures on a monthly basis using a user-friendly dashboard approach to monitor and celebrate success. View example of dashboard. Other dashboard development ideas include Sample geriatric assessment instrument and ED patient flow analysis example. Visit the website to see how to make a dashboard.
