The cases of Mrs. Cado and Mr. Ransyshyn illustrate complex transitions of care where advanced assessment skills and discharge coordination are required. Emerg physicians tend to think of their sphere of care as being limited to the ED but we are often the managers of care as patients move “through” our department. We interact with both the “upstream” (where the patient is coming from) and “downstream” (where the patient is going.)
A transition of care is any time a patient moves from one site of care to another:
- From home to the ED;
- From ED to home;
- From the family doctor’s office to the ambulance crew;
- From the long-term care doctor to the Emerg physician;
- From the Emerg nurse to the community care agency who is providing follow up care;
- From the emerg physician to the inpatient surgeon.
Emerg physicians know how complex , complicated, and loaded with risk it is even to transfer care of a straight forward patient in our own ED from one Emerg physician to another. The EM literature is full of studies of “hand-overs” as a source of medical error.
The assessment and disposition of a complicated vulnerable older person is far more complex. Older patients can be cognitively or functionally impaired, with a new or poorly understood condition, sometimes with three or more care providers, and a significant change in function, cognition, or social situation.
Emerg physicians need to have a large toolbox of strategies to minimize the risk of harm and to maximize the quality of care to older patients as they move through our EDs.