Summary
We hope you have added to your knowledge skills and attitudes about Functional Assessment and Discharge Planning in the Older ED Patient. We introduced some of the principles of Geriatric Emergency Medicine and suggested ways to put those principles into practice. We presented a framework that integrates all the components of ED assessment – physical, cognitive, functional, and social – that you can use to structure an approach to both simple and complex cases. Transitioning complex older patients from the community and ideally back again is a demanding component of Emergency Medicine – and ideally one that we work on with an interdisciplinary team. Having a system in place will make everyone’s life better!
You may also want to review the modules on Atypical Presentations and Trauma and Falls and Cognitive Impairment which have specific relevance to this topic.
Review the Learning Objectives before proceeding to the Knowledge Check.
At the end of this module the learner should be able to:
- List strategies for gathering information about an older patient in the ED
- Identify essential parts of a discharge plan for an older patient (the importance of cognitive and functional assessment, ambulation, ability to provide self-care, safety and establishing a follow-up plan appropriate for the vulnerable older patient.)
- Name the Activities of Daily Living and Instrumental Activities of Daily Living and link them to safe ED discharge
- Establish members of the health-care team with whom to share care tasks; (ED nurse, family physician, community care provider, long-term care providers; ambulance crew)
- List strategies for communicating with “downstream” care providers. (call long-term care; send written information back to LTC; fax a copy of chart or discharge summary to family doctor; provide a legible written copy of clinical record and plan to the patient; notify in writing the community care nurse about changes in care plan.)
Discussion: Summary
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Good information
k
literally 100% of the patients i see on a daily basis on 2 of 3 days meets minimum 1 ISAR criteria meaning they are high risk. every couple days i get a patient without any of those criteria, but it just reinforces the need to think more wholistically and past the point of discharge to try and brainstorm and pre-emptively mitigate the issues that are at risk for developing. on the flip side, having the ISAR score to use may help when trying to justify admissions to QM staff who have no concept of why certain patients require admission and try to block them
I like how you can gather so much information on ADLs quickly by asking “can you take a shower by yourself?”.
Valoración integral al momento del egreso
Limitantes para el egreso al paciente, o qué cosas lo pondrían en riesgo de reconsultar nuevamente en poco tiempo
Get up and go prior to discharge with referrals
get up and go test
Principles of Care of the Older Patient
safe discharge communication and planning
I learned the domains of what to assess when dealing with geriatric population, assessing all aspects of their needs will be beneficial to their treatment and outcome
I will be meeting with local nursing home directors to improve transitions into the ED and back to the facility. I appreciate the value of including ADL/IADL inquiries into all senior ED evals going forward
Importance of assessing the full spectrum of the presenting geriatric patient; looking beyond the presenting complaint to find the multifactorial reasons for the patient’s presentation.
I have learnt the proper assessment of the older patient prior to discharge. In other to safely discharge such a patient. The get up and go test is going to be a sure addition to my practise.
difference between ADLS and IADLS. Discharge and scoring for discharge of the elderly. Care instructions for the nursing home.
This was a great module. I definetly am quite thorough when assessing the elderly and rely on nursing home information and collateral from family/friends. I think it is vital as a lot of the meat of a case is from the history. Getting information re baseline is also very helpful in the ED as you can already start figuring out what the disposition of this patient may be just given the baseline and how they are presenting now to you. I also have a low threshold to fill out a CCAC referal for services or a geriatric referral when i am concerned. I think the questions about can you toilet yourself at home and the get up and go test is a great – I use the latter often.
Call the nursing home to get a better understanding of the patient if they are unable to communicate efficiently with me. Talk to family to get a picture of what their home life is like and their PMHx.
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Understood!
I learned about the 4 domains. I’ll keep these in mind when assessing elderly patients for discharge.
ok
ok
Good review.
Difference between ADLs and IADLs. Utilizing interdisciplinary team to ensure adequate assessment of ability to return to community.
interesting point
good review. ADL vs IADL was new for me.
good review
good review
hey
lots
Excellent review.
Overall good overview of all that is needed for successful discharge plan and transfer of care
Ensuring labs, d/c summary and a reviewed med rec list goes to the transferring facility. Personally ensuring calls to staff RN or family to give report at time of transport.
ADL vs IADL and the get up and go test are very helpful
Try to involve various members of healthcare team and patients family, assess IADLs and ADLs.
The wholistic care of the elderly patient both in the Ed and. At home . Any changes made to management should be clearly stated.
Other home activities to keep in mind during discharge planning
direct interview, collateral interview with family, nurseing home staff and EMS about home situation.
important to conduct functional assessment prior discharging patient
great info
discharge planning is very important
tr
discharge planning is as important as treating the patient. Proper communication with patient, family, and other caregivers is important.
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There is definitely a challenge with providing safe discharges for these patients. The first case of the lady with a shoulder fracture is a very common example at our ED. It is sometimes maddening that the lack of adequate resources forces me to admit some of these people; using more Medicare money and exposing these patients to nosocomial infections is not cost-effective.
Collaborating with physicians, social work to maintain independence and treat underlying causes, and multiple reasons such as polypharmacy
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good definitive communication with written instructions and involvement of pt/ot and ancillary services is essential
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Definitely a great module. A reminder that the elderly patient is more than just the physical person sitting in front of me but that their social, functional situation also co tributes to their overall recovery and that is something that must be considered in their care.
Assessing and Discharging a Geriatric pt is a team effort
Multi-team and level approach.
Adequate assessment, treatment, and plan discharge.
Make sure no gaps in the follow-up plan.
Involve; patient, family, caregiver, and primary physician.
more holistic approach
investigate all the domains from the beginning
Informative
Important to establish patient’s baseline in terms of cognition, function, ADL, social, in addition to accurate physical assessement. Once these are established, discharge plans can be done effectively in relation to the above. Also, in transfering care, it is important that diagnoses, changes to medication, follow up plans, etc are effectively communicated.
helpful information
Ask more questions about abilities to do ADLs at home. Don’t only ask if they feel safe going home.
Too much to name
adietrich
good
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pay attention a lot to non clear medical assessment only that be aware of all support that patient needs other then pure medical assessment
Medical assessment could be sometime very simple but may affect and complicate somebody life a lot and all other services are really essential for good outcome
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use of ISAR tool, nursing home communication
will need to work on nursing home strategy
communication is key
useful.
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ok
ok
Nice information
valuable information
awesome education
ADLs and IADLs
Using the ISAR as another tool or part of the history taking
I will start sending copies of labs, imaging, workup, disposition back to the NH after an ED visit, if it is HIPPA compliant as most NH residents are unable to complete a record of release form
it is important to include all aspects of an assessment, including social, functional, cognitive, and physical
interview with patient and family
Continue to assess patient’s safety prior to discharge.
All great points.
valuable points
good info to review
The importance of including Social, Functional, and Cognitive assessments to my routine physical assessment to geriatric pts in the ED, the importance of person-to-person communication when transferring pts to and from nursing homes.
Will improve written communication back to care facilities from ED.
ADLs and IADLs are very good assessments to consider when assessing geriatric patients
adl vs iadl
Important to review ADLs and discuss outpatient strategies and home care
evaluate ADLs and IADLs before discharge
All very helpful
great points
ADLs (1st 20 minutes) vs IADLs (things you learn when you leave your parents’ house
Comprehensive assessment leads to safer discharge and better patient outcomes.
The importance of assessing the patient through a holistic approach by conducting social, cognitive, physical and functional assessments. Also, the importance of taking time when assessing newly admitted patients and collecting pertinent data by contacting staff from their previous facility.
Agreed especially if limited information was sent from nursing home.
assess
Comprehensive assessment of patient requirements and rationales helped provide a great outline in knowing if a pt is ready to go home
the importance of assessing health status domains: cognitive, functional, social
teamwork and transfer of accountability to prevent early ED readmission
the importance of self-managing upon discharge
really liked the highlighting of how much teamwork is required to safely discharge elderly patients home
I see the need to gather as much information as possible to obtain data for diagnosis and successful discharge planning.
will focus more on finding out what the situation is with my patients when they return home
there is a lot of planning involved in discharge of patients
must consider the environment patient is returning to, upon discharge and the ability to function,
disseminating of discharge instruction to the relevant parties involved.
Huge focus on social/living arrangements with elderly patients
Strategies for safe discharge
Better communicatrion betwenn ed and nurses from nursing hm
Have better communication between the Ed and the nursing home use of the order sets
discharge planning is important
helpful
more in depth planning for discharge, especially in those elderly returning to a home setting where help is maybe not readily available.
safe and effective discharge planning,
The isar
like the domains framework
helpful
The use of forms for transfer of information from hospital back to NH staff. Standard forms for NH,s to use for transfers to Emergency departments would also be very useful.
this module has helped me better understand safe and effective discharge planning, and the importance of communications between facilities when discharging patients
This
helpful
excellent learning
acute assessments
Accurate assessment and discharge planning
discharge is important
accurate health history has to be taken
k
Asking the right questions to obtain a more accurate health history
thorough assessment, consider meds, care plan for optimal care
Call nursing home more often
Write a résumé for nursing home more often
ensuring safe discharge for the patient and communication between ED and nursing homes
Nurse-to-nurse handover is a new idea to me. Also, I embarrassingly forgot to think about SDM and DNR considerations.
Tools for more detailed discharge planning and functional assessment tools.
functional module
safe discharge planning
The discharge process is just as important as the assessment and diagnosis process to ensure the right care for our patietnts
I really appreciated the Emergency Department Transfer Report for Long Term Care Patients!
this reinforced our existing practice, and provided some important reminders about whole-person care. I will do written discharge instructions more often.
the importance of safe discharge planning in the elderly
ADL IADL
ISAR
Evaluate ADLS and IADLS in ER. -first thing to go is bathing
ADLs and ILDs History
Discharge planning
Ensuring a safe discharge plan for the at risk patient will likely save a repeat visit for either you, or a colleague.
many things, very interesting module
Found some tools to employ for interfacility communication and reinforced the value of all members of the team having input into the patient’s assessment, needs, and plan of care for successful discharge.
Remeber to assess the functional/cognitive/social assessment of patient with acute functional decline.
Will work more on establishing functional status pre-presentation to the ED
It is the whole picture, not the injury
reevaluate ADLs
Atipical presentations
assessing physical, cognitive, functional, and social skills of the patiente
need to develop a more robust communication method with NH staff for both pre- and post-ED visit
Importance of the transfer of information once discharging an elderly patient: will now try to participate more actively in the transfer by writing summary notes to the caretakers.
All the modalities of assessment that are required before discharge
I think the most valuable point is that you need to take a holistic approach to the patient. Consider all aspects of their care including social/functional/cognitive abilities before discharging. It is also important to ensure that you are discharging the patient to an environment that supports their current care needs, not just the care needs they had prior to coming to hospital.
functional/cognitive/social assessment of patient with acute functional decline, rather than just doing physical assessment
Comprehensive assessment of the elderly people
How to assess
Who should be involved in assessment process
Who should be involved in discharge process
Ensure the patient to be safe on discharge and in long term as well
Geriatric nurse, physiotherapist, occupational therapist, pharmacist and social workers are essential for a practice
implement screening tools, address each area of function before discharge
evaluation tools for screening anyone over 65. I like the subheadings (physical, cognitive, social, functional) and will utilize them in my notes for thoroughness.
Communication is key when patients present to hospital and it remains just as important when they get discharged
communication is the key when upon presenting to ER and on discharge
I liked the transfer of care form for the LTC facility. I would like to see one for our ED.
Comprehensive practical review
Systematic approach for investigation and disposition of geriatrics’s patients. It is a teamwork. Communication is essential.
make a complete assessment of each area
Of the four assessment domains the one I forget the most is social. This has been a good reminder to always perform a targeted social assessment when dealing with older patients, especially those that are being discharged home.
I really liked the focus on transfer of care and repatriation to nursing homes / LTC. I think a phone call is necessary as the services provided at these institutions are so variable. We often forget that when a patient is sent to the ED that someone is worried about something, and a quick phone call to identify that worry will certainly expedite things and make transfer back much more palatable.
Excellent review
liked the review
really good module
There are many factors to consider to keep patients from returning to the ER after receiving treatment
good legible communication , multidisciplinary approach to care after discharge . knowing how each pt will cope at home or passing info on to nsg homes for care when pt returns
The importance of physical, social, functional and cognitive assessment in discharge planning for older people.
The Domains of care is a very simple way to get a good overview of the major issues with the patient.
However, a lot of the theory in these modules depend highly on institutions with resources like dedicated social workers and physiotherapists for the emergency department which is not practical in my country.
application of a more holistic approach to discharge of the elderly patient
Need to communicate better with patients relatives and caregivers before discharge. I also have a better understanding of all the different categories that need to b assessed before the patient is discharged.
nice module, interesting point of view
desarrolle destrezas para poder abordar mejor a los adultos mayores
como manejar estos pacientes
I will be more careful when I discharge a patient.
oo
I will pay more attention to the adl and iadl before discharging older patients.
Structured assessment – the use of printed sets would be useful
I hope you checked out the list of Downloadable Pre-printed order sets and protocols on the Related Resources page.
Going through this module has enlightened me more on the mamanegement of elderly patients presenting to ED, from clinical assessmen, through decision making of safer patient disposition. I have learnt the importance of communicating with relatives and caregivers as a way of obtaining vital information relevant to diagnosis and decision making which in many instances cannot be provided by the elderly patient themes elves.
I have learnt the role of obtaining important scores such as ISAR in addition to the various clinical scores we use to grade severity and prognosis of clinical illness. I have also learnt the importance of using the scores in decision making for safe patient disposition.
I have also learnt the importance of a multidisciplinary approach to the care of the elderly and the need for a coordinated approach between teams for the care and continued care of elderly patients who usually have multiple comorbisities and social issues all of which impact significantly on the outcome of the current ED presentation and on furtute admissions/ quality of life.
Provide a thorough assessment of medical, cognitive, functional and social issues prior to discharge.
I learned a lot of
I learned a great deal.
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assessing for ADLS and IADLs
As I do not routinely work in the ER I will try to make sure my “upstream” care of patients (and proper documentation) makes it easier if they need to transfer to the ER. When in ER, or hospital, I will make sure more complete (functional, emotional, social) assessments and proper interventions are done before discharge.
I agree with rubenh77.
This module highlights the complexity of discharging older patients. The key is having the ED staff aware of this complexity and in agreement re using the ISAR, calling LTC and taking the time to document the transfer back and plan.
The key message to me was don’t just focus on the physical problem – ask yourself how the patient will cope at home. Need to do a social, functional and cognitive assessment before can safely discharge someone. Also, getting info from the nursing home and sending info back to them re the plan are important.
I think the most valuable point in this chapter is the discharge evaluation of the patient. Taking into consideration the safety, and self care and family support need it to go home. Or use home care services to ensure is a positive discharge.
direct interview of patient, family caregiver others ie even superintendents. medical surgical information and detailed drug use. ability to get up and go, bathe dress and toilet. nursing, ot, sw, family md ltc staff. call caregivers send dictated notes clearly written prescriptions electronic CCAC referrals