Background:
Wellington Regional Hospital (WRH) is a tertiary-level hospital and trauma centre in New Zealand. Of the 61,113 Emergency Department (ED) presentations in 2022, around 17% were either >75 years or >65 years and Māori/Pasifika. A significant but unknown proportion of them are living with a degree of frailty. Frailty is associated with an increased risk of unnecessary admission, inappropriate tests or interventions, being admitted under the wrong service and overall poorer outcomes.
A major challenge in caring for older people in the modern ED is the recognition of frailty and completing a timely comprehensive geriatric assessment (CGA) to holistically manage these patients.
Change:
In 2020 we established an Acute Frailty Unit, linking with both ED and General Medicine. This was an evolution from a small hospital-wide multi-disciplinary geriatric consulting team, and the first admitting geriatric medicine service for some years. During the development of admitting processes for the ward, we identified the need for a dedicated geriatric skill-mix in the ED, based on the GEDI principles. These skills were detecting patients living with frailty and providing interventions in a timely fashion to avoid unnecessary admissions, support discharges from ED and admit the patient to the correct service at WRH. In August 2022, we developed and established a GEDI CNS role to address these goals, and provided an opportunity for skills sharing with ED colleagues, and promoted patient-centred care. In the initial phase this has been a single clinical nurse specialist in working hours.
Between October 2022 till March 2023 (104 CNS working days), we have screened 2523 older patients for frailty. 258 were seen directly by GEDI CNS and 142 had a CGA completed. Of these, 72 patients were discharged directly from ED, 81 were managed by Acute Geriatric team and 79 patients were admitted under General Medicine with CGA and geriatric input. Verbal feedback from ED and General Medicine has consistently mentioned a positive impact on flow on patients living with frailty presenting to the ED, improved clinical decision-making by ED and inpatient teams using the information gained from the CGA, and the opportunities to collaboratively coordinate the discharge process in the ED.
Learnings:
The introduction of the GEDI CNS role has made a positive impact on frailty recognition, supported discharges and streamlining of patients to more appropriate services. We have also developed an educational relationship with our clinical colleagues highlighting the principles of good geriatric care.