Consulting the Team
“It takes a village!”
High-quality assessment and care of the older person in the ED is a team effort. Admissions are avoided and outcomes are better if you can mobilize a team to help assess the person who has fallen and to arrange for safe discharge to the community.
Team members – including the MD — need to be familiar with each other’s roles and be able to communicate effectively with each other.
Some departments have:
- a designated advanced or focussed practice nurse or a social worker to coordinate the non-medical components of the visit;
- access to a physiotherapist and or an occupational therapist who can do mobility and function assessments
- a pharmacist available to assess medication use, interactions, and compliance;
- access to community-based care coordinator to arrange additional home care or assessment of the home for safety and mobility
Mr. Cooper
The following video segments all relate to the ED assessment of Don Cooper, a 78-year-old man who has fallen at home where he lives independently. He came by ambulance because of painful right hip and an inability to walk. Mr. Cooper lives alone in a two-storey house with bathroom and bedroom on the second floor.
His medication list includes:
- Amitriptyline “for tingling”,
- Clonzepam “for nerves”
- Terazosin “for prostate”
- Ramipril and Atenolol “for blood pressure”
- Diphenhydramine “for sleep”
- Glyvuride “for sugar”
- Warfarin “for my heart”
- Colchicine “for my gout”
- Watch each of the brief videos about how different professionals approach this case and the various contributions they make. Think about your answer to the question below as you watch.
- Name three tips that you learned from your colleagues that you can use next time you’re assessing an older person who has fallen?
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Discussion: Consulting the Team
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– involve a social worker or a liaison nurse
– bring the family and validate with them
– ensure follow-up with the CLSC externally
– involve a consultant for hospitalization if necessary
Conveniently I am the ED geriatric consultant. However, if not available other options include contacting patients families, transition services/home care coordinators, and temporary transition/rehab beds in community
we are currently trying to establish a geriatric Ed. I would appreciate any recommendations or suggestions you have. If you could provide me with any issues / barriers you have faced and would love to see the protocols you have in place at your facility.
If you can help me please let me know
Ensure the patient has a support person who can assist them at home, if no one is available, may consider a social admission to provide time for coordinating a safe discharge.
observe them, observation unit admission, social work, physical therapy in the morning.
have RN. social work, case management assess patient for home status, funding, physical needs, have family involved
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We sometimes have them wait in the ED overnight for case management to speak with them in the morning.
its very tough. our pharmacists refuse to do med recs. so do the nurses. it all falls on the MDs. everything eventually falls on us, as we are at the bottom of the foodchain in my particular system. luckily we do at least have a SW but not a 247 in person on. other depts where i have worked have better options including PT in the dept during daytime hours, 24 hrs a day in person SW, and pharmacists who are more willing to help w med recs and med discussions w patients.
nice
We try and do an all-in-ne assesment, but basically we have ourselves and one nurse only
En nuestros servicios no se cuenta con la mayoría del equipo multidisciplinario para una evaluación íntegral, por lo que de manera general se valora el estado basal funcional del paciente y se verificará el apoyo social que ese paciente presente y necesidad de solicitar intervención de trabajo social
Que cuente con fuertes y reales redes de apoyo, me refiere a familia o incluso el recurso económico para poder afrontarlo de manera individual y privado si se pudiera
discharge planning are in should coordinate care and discuss home living situation with family members or caregi
discharge planning
close outpatient follow up and possible geriatric review
provide adequate outpatient follow up
Admit the Patient to get review from inpatient Allied health Team to make sure safe discharge plan
ok
we will be a GEM
Very informative videos
no GEM
OT PT SW referrals
Pharm rv for current meds
Make sure patient has responsible/support to be discharged
Discuss with patient and family, admit if concern for inability to handle ADLs
Right now we just have bedside nurse and MD assessment.
AGREE with above- dc planning is one of the most impt aspcts
we may need to keep patient with us for a bit longer to observe and ensure good enough functionality before discharge and elicit the help of family members of friends to give support
finding out whether the patient has a good support system that can assist him in his discharge or there is a community physician/family practitioner who can follow up with the patient after discharge.
I usually observe them transfer and get around in the ED. As well I find out what kind of dwelling they live in, who and what are their supports at home, if they need extra supports, I chat with the PT if I think they need a gait aid for safe d/c, and place a CCAC request if I think they can go home with some supports in place. I speak to family and find out if there is extra supports and If If I further think the person would benefit from a greater assessment, I place a referal for GEM – geriatric NP team.
I have to rely on my own and my nurses’ judgment
speak with the family and possibly a social worker
Determine what supports hes has
ok
Ensure pt has a plan in place for discharge ie family or a friend that could visit regularly/stay with him during recovery and assist with day to day tasks, submit referral for temporary CCAC help
LHIN referral, family support, lifeline
Providing out of hospital care so we never have a team available. Pt is transported to ER and / or CCAC referral is completed to get them access to additional services
Friend/family support
Family support, life line,
LHIN referral, family support, lifeline
Thorough review.
Write referrals, follow up
fully explore support system prior to discharge – OT, Physio, homecare needs (RN/ RPN) family and friends – create individualized discharge plan possibly
do they have support systems in place at home, home care, care giver, assistive devices, life line access,
do they have supports at home, home care, lifeline? family
do they have a support system at home or in their nursing home to help care form them?
Make a community referral
search to see what resources are available thru the community that can improve the pateints way of life and thus reduce unwarranted visits to the er. family involvement is also highly recommended if possible.
ok
family decision
if unable to maintain own ADLS, IADLs ensure family able and willing to assist
Assess the pt’s needs and capabilities for safe daily activities and the potential need for aides or help. Ensure these resources are in place before discharge
I’ll ask for the physiotherapists and social worker to see patients that I’m doubtful about.
teamwork and understanding realistic expectations is important. realizing expectations should be the goal of all stakeholders
walk test and family support.
great review
ask family
make sure they are able to be taken care of at home , make sure there is no risk of sending them home
Ask the patient to perform simple tasks that they would normally do at home and view them to make sure they are able to ambulate properly, get up and down from chairs, go to the washroom without any help etc
home environment, family support and pts injuries
good info from the different team members
I ambulate the patient to make sure they can walk on their own or with a walker. The nurse or I speak with family to make sure the patient has help at home and can arrange follow up with their GP.
We are just in the process of developing this role in our site. Currently relying on transition nurses and OT/PT to assist
Gather info from shareholders, try to involve GP, ensure follow up
Talk with family about care plan, have responsible party. Set up appts for patient.
Family discussion, make sure the family is involved in post discharge instructions.
speak with family
collaborate with family and home health care agency
Complete full set of scans and checks
Compare to baseline
Second opinion
If the patient is going home and no one is with them, the ED nurse and I need to agree completely that they will be safe to discharge. I will enlist family members with the patient’s permission, if available. I have a Case mananger available during the day that I can also request assistance from.
SOMETIMES VERY DIFFICULT. INVOLVEMENT OF FAMILY INTEGRAL AS WELL AS COMMUNICATION WITH PCP.
collaborate
refer to social services
Case manager consult
Ensuring good family support is a major aspect. Also discussions are made with the social worker if there are home issues.
OT?PT Social worker and family support
pain management, and using the strong side of pt to get pt mobile
ok
good
.
Okay
.
ok
Make some of the aspects that a MDT do as part of your history, physical and discharge plan.
good advice
ok
Ok
Fortunately, I have access to all of these specialities. If I didn’t, I would be in contact with patient’s family to see if they would be able to assist with anything. If I was worried about patient safety, I would discuss admission/short term rehab.
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Without an entire discharge team it becomes difficult. Using the family to try to best understand and support the patient at home is a good strategy. Essentially, you are trying to play a portion of each specialty’s role by doing this.
ok
many times
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x
–
ok
So important to include everyone.
ok
involve family/ support network, social worker, etc.
ok
we do have full geriatric assessment team.
However if not I will involve OP, Social worker, physio to assess patient for safe d/c
Include SW, know community resources ( ADRC), involved family
coordinate care
Currently we have a social worker team that does a great job with discharge planning. Medications are checked by a pharmacist. Eventually it is up to us to make a disposition if the pt is safe for discharge or admit for social placement. We do not have a complete team yet but hopefully we will soon.
The emergency room physician determines if the patient can adequatly be taken care of at home.
assess support at home such as caregiver, ability to arrange sitter or home health, and personally arrange close pcp or speciality followup
ok
x
advocate for patient safety!
ok
Team , resources issues
problem with number of staff
support is so important
ok
discussion with the social worker and arrangements with community nurses for home visits. also educating the family as to better way to take care of patients is important.
Excellent information. As a previous homecare nurse rapid discharging without plans or supports in place does not support the patient and often results in a hospital/ED return visit.
can they walk, get dressed, and feed themselves safely
great information
great vidoes
..
great
.
Local ADRC, involve family and friends as patient supports.
Short-term admission so these things can be arranged outside the ED, or outpatient referrals to these services with adequate family support while awaiting these assessments to take place.
We engage case management to arrange for outpatient follow up and home safety evaluation.
smaller towns have more of “village” support. Get info from support system and ask what they are able to do, contact home care
recommend the use of community resources available to seniors i.e. social worker who has the authority to conduct assessment and make relevant recommendation for appropriate service .
utilize resources available and consider perspectives from other care team members
We have one
As a paramedic it is not unusual for us to set to a home for a “lift assist”, person has has minor fall or has slipped off a bed, though not injured we often take opportunity to encourage CCAC involvement if not already utilized or refer them to our community paramedic program
the doctor can conduct thorough assessment of the patient heath condition,along with nurses who can perform ADLs assessment.
also collaborate with social worker for community base resources , i.e personal support care staff,and ensure that relevant services are arranged before the patient is discharged home.
important to get VNA services
Assess patient’s safety for d/c home and supports available to patient to make a successful d/c home based on thorough assessment of patient’s specific needs.
do thorough assessment and history yourself. referrals if necessary
do a throughough history yourself.
Involve nurse, case manager, and family in discharge planning. Nurses can complete basic ADL assessments if a PT or OT is not available. This will help gauge the support needed for safe discharge.
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collab with interdisciplinary team
ok
talk to family
trying to get in touch with other HCPs and getting a quick baseline to review as a practicing hcp myself
involve nurse with walk test/some of the testing as above, case manager/home health to see before discharge, involve ++ family, call GP
collaborative effort, case manager
With normal evaluation and imaging, ambulatory testing is a must. Also discharge with family or caregivers
small hospital with limited resources, we can sometimes have PT eval patient. WE have many social admits
discharge planner, collaboration of nurse, ot, pt, etc.
discharge planner
The nurse can do the assessment for ADLs and consult with the physician as well. If you have access to other specialities like PT and OT then it may be better
social worker, call for family doctor
We have a discharge planner and social worker in ED to help in assessments with safe discharge.
ok
We recently added a geriatric nurse to our team. What a difference it makes ! When she is not there, we have to do the job !
We complete the interrail EDS screening app and depending on the results we refer to social work and home care
SW
Asessment
AH review
community follow up
social work to increase services
using home care resources, community elder resources, and primary care provider
Call family or the residence where he lives, make a social assistant assess his leving place
Challenging! Depend heavily on the nurses to help; often need to keep patients in the ER until the home care nurse can assess; otherwise output home care consults on an urgent basis; difficult in small community ER/hospitals
communication between providers in community is key
GEM nurse assessment
getting other heath-care professionals involved, listen to the patients need, assess their support system, assess pts overall condition, get others involved
In the absence of a geriatric team we would review the patient is able to walk prior to going home. We are more inclined to admit the patient if there are any concerns, even if only for a single night, in order to see physiotherapist and geriatrician at a later date.
Can’t walk, can’t go home
Try to control the pain as soon as possible – not after imaging
Get help – its a team sport!
nurse, pharmacist, external doctor.
OT or PT
making sure everyone from the interdisciplinary team is assessing the patient and discussion with others is evaluated to come up with a discharge plan
good information
k
No
pain control, assistive devices and education
agreed
helpful
k
ask the questions related to ADLS, home care, and getting in/out of bed yourself
Consult with the team and refer to practice guidelines
individualized discharge plan is important
To ensure that an older person is safe for discharge in my department, I would consult other members of the healthcare team such as the physician, OT, PT, and social worker to gather a full assessment
Family and multi-specialty involvement
Family involvement, close follow up with pcp
We now have the team, justrecently . Before that it took a lot of team work and discussion to do the same job without the knowledge and it took lot more time .
ok
case manager
social workers
in depth conversations with family members
update to GP
As we do not have such service all the time. our default poistion is admission for inpatient admission if I think the risk is high of falling/failing discharge
NA as we have full team with Geri exposure
-collateral history
-nursing and physician assessment
-home care follow-up
-social work involvement
walk test, inquire about home situation, discuss discharge planning with family/friends, involve GEM nurse
same thoughts… GEM
Lots of family involvement. Ensure close follow-up with GP. Lower threshold to admit, even for a couple of days to ensure things will function smoothly at home.
No formal team in my dept – we do engage pharmacy and social work to facilitate safe discharge
Unfortunately, no dedicated OT/PT
no
Involve family in the discussion, consult social work, OT and home care to help ensure safety.
social work may be bLE TO HELP
nice
Intersting more in our patients
referral to geriatrics
we have access to pharmacist, physio assessment and have an in home assessment that can be activated in the community upon discharge
We are fortunate enough to have access to aged care assessment nurses 7 days a week 7am till 2200. However when this is not available I ensure a thorough social history, that this is confirmed with collateral history by family/close friends and that they have someone to go home with. They have to be able to mobilise in the department. In reality though we often admit either to a short stay unit or to a medical ward elderly patients due to increased risk of falls overnight and also so taht more thorough allied health input can be had.
Referral to Geriatric Assessment and Intervention Network in the community
we have a case manager in the ED.
Luckily we do have excellent geriatric nurses in ED and also physio. If they need to see a pharmacist or OT that can be arranged by admitting them to our ED short stay unit
Liaising with other department – e.g. Physiotherapy, occupational therapy, social work, pharmacist, community care coordinator
good social support-relatives
if not low threshold for admission
All elderly with fall should be subjected to baseline functional assessment, fall assessment, Gait and mobility assessment and must be asked in history for substance abuse, previous hospitalization due to fall, pain and stiffness, current medication and always look for medication causing orthostatic hypotension.
agreed
I like the thought of revisiting medications and trying to eliminate any unnecessary ones to reduce risk of confusion and adverse affects that lead to increase fall risk. Collaboration with family doctors are important since it could ensure pts don’t have multiple doctors prescribing meds without evaluating the most appropriate combination indicate for the patient.
Why did the PT recommended a single point cane versus a 3 or 4 point cane?
I’m not an expert, but a single point cane seems to be recommended for “light” weight situations where assistance in balance is all that is required. A four point is best post surgery or trauma where greater support is needed. It seems a four point as a draw back in that some don’t fit on a step and won’t assist with stairs. Just a thought though…
k
community liason nurse assessment and early outpatient followup
once discharged client should have close f/u with GP and all avail supports
thorough history – if deficits could impact safe discharge…access home care, family members, family physician etc to fill gaps
cognitive assessment (may need blister pack, home care, referral to geriatrician)
reassess meds (eg stop benzos)
All ER should have more Pharmacist coverage specifically for the Emergency Department
would be nice to have OT/PT, I wonder if the government can look into funding this!! Also expanding the Geri EM Nurse role
k
We have a GEM nurse during weekday business hours. After hours/on weekends, we often admit patient for the geriatric issues to be sorted out.
We have great ED team with discharge planning nurses (similar to GEM) and a pharmacist. However we do not have (and would love to get) PT/OT
I couldn’t watch the video
yes
Great module
We have a dedicated OT/PT team to assess the functional needs of patients within the ED. Recently this service has been augmented by an inpatient frailty unit (geriatric medicine) who have Older Persons’ Advice and Liaison OPAL nurses to assess patients in the ED, both for suitability of admission to the frailty ward, but also to assist in planning options for discharge, such as respite admissions. One extra discharge as day pays for the OPAL nurse service (UK NHS costings).
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Have a home assessment done by extramural nurses. Rapid access for elderly patients for OT and PT. Consider personal care workers as well if they have coverage. Collateral history with family and health care workers
can watch the video, will not down load
the nurse makes sure
we do not have gem nurse or geriatrician .Asseseement from doctor and nurse are done ,refer to social worker, if going back home,refer to the extra mural nurse for continuing of care and assessment. That patient would probably admit until all in pace at home for discharge.
Involve family and homecare and discuss home living situation.
Excellent review of how all components of the multidisciplinary approach fit together. Excellent review of falls history by nurse – including a few features I had not really thought of such as falls near misses and change of behaviour to avoid falls.
Really a lot to consider….
find other resources to communicate to for suggestions on assessment, family support,
Not applicable im prehospital
It takes a village.
many more things to consider
make referral to external partners
not applicable
Good assessment and good communication, high level of suspicion
excellent videography
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good module
good thoughts everyone
use competent person with patient to assist if possible, admit for obs until assessed by social and physio when possible
We have access to a good ‘rapid response’ social services team who can coordinate the assessment of the patient and also organise further assessments once the patient is at home.
Assessment of the patient and educating him about the risks and changing daily activities in order to avoid falls in the future. Coordinate with his primary doctor with written explanation about the current concerns for the patient’s condition.
We don’t have GEM, PT/OT or geriatrics available in the ED. CCAC for home assessments. GP follow up.
find other resources to communicate to for suggestions on assessment, family support,
Examining history and advice to caregiver may reduce the risk of falls; arranging home visits from the district nurses may assist
We assess and try to identify any potential risk factors that predispose the patient to falling. Relatives are contacted and counselled on the injuries of the patient as well as what the patient requires for rehabilitation. Social workers are involved to aid relatives or patients who do not have relatives. We also have review clinics to follow up on patient care. For those patients who live alone and have no social support we admit to hospital as we don not have 24 hour social services in our emergency department.
educación a la familia para identificar factores de riesgo
you have to make an integral evaluation os physical, social and cognitive evaluation prior to discharge
educating family by warning signs
I tend to rely very heavily on relatives and spend a lengthy time counselling them and assessing whether it would be best to allow the patient home. If the relatives will be fit to help them and be vigilant or adhere to appropriate follow up. As far as I know occupational therapy isn’t available in the public health system. Physiotherapy appointments are scheduled for weeks to months in between sessions. But I still send them with the letters and hope that they can get the appropriate help.
options that we have include heavy involvement of the care givers until physiotherapist, social worker or other team members are able to assess the Pt. or hospital admission when there is no reliable home support.
Assess patient properly before discharge. Assume role of not only doctor but nurse ,physiotherapist, pharmacist, occupational therapist.
Improve my assessment and history taking skills, assess the pt. knowledge of medications and compliance with medications, ask pt. to demonstrate skills needed to be independent such as ambulation, sitting to standing position changes, determine the pt. ability to identify when assistance is needed and make a plan for obtaining assistance when needed.
Refer to the social worker
hy
xx
kk
social workers or outpatient geriatrician
Refer to GEM, SW, CCAC
perform a social function assessment before discharge and involve family
I make them mobilize and observe them. I would get family involved to make sure instructions are followed. Likely he would end up a short term admission to assessments and community supports are organized.
It depends what level of ER the pt got to but in General it is always advisable to let other teams take a part in Rx plan when it comes to elderly.
Quick response team available,or hold for do ail work
In the one community I work that does not have geriatric assessment available, I can access most services myself (eg. I make my own CCAC referrals), and most patients here belong to a family health team. If they are well enough to be discharged home, they can follow up with the primary care provider and have access to the pharmacist, OT/PT, social worker. I find we do end up admitting more patients then I do at my larger site with a dedicated GEM service, but there usually isn’t bed issue as it is a smaller community.
We have a QRP (quick response team) that can arrange next day home care and continuing care for our seniors. We can ask for a physio or pharmacist to come down to the ER during bankers hours. Teaching docs and residents to be more geriatric aware
refer to the social worker
consult social worker, CCAC
when I work in rural communities, I have access to their primary care EMR (Oscar). I send their family MD a quick note about their ER visit and any changes to meds I made.
We have GEM, Social Work, Pharmacist assigned to the ED, Physiotherapy and CCAC, all available during the daytime only. If there is any question about a safe discharge, the patient may be held or admitted as a short stay admission for more comprehensive assessment during sociable hours.
no GEM, no physio, no OT, no CCaC avail on urgent basis, no likelihood of daily PSW support available. Admit to hospital where pt will suffer hospital associated disablity and decline. Polititians will continue to garner votes telling people their government will adress this current condition of non-care of the elderly. What planet were these “colleagues” from?
No Gem, OT, PT. NO geriatric assessment available. We rely on CCAC and the primary care physician. Given the meds on arrival I would be reluctant to be cared for by his PCP.
OT, PT, social worker if feel they need more supports. Outpatient memory clinic appt or geriatrician if applicable. Call family for collateral.
in the absence of the gem nurse the patient will be seen by the geriatrician also if available by ot and pt.the outside pharmacy will be called re drugs and dispensing of drugs
Many times, the discharge planning RN would coordinate care with VNA to do a home assessment.