GEDI patient screening, assessment, decision-making, advocacy and intervention

Screening and prioritisation

GEDI patient identification – this is undertaken via visual scan of arriving patients or patients already in the ED, FirstNet/EDIS scan, referral from primary ED nurse or doctor, consultation with paramedics transporting patient to hospital and phone referral from an RACF or GP.

Prioritisation of patients to be seen: The principles underpinning which patients the GEDI team will see are:

• Residents from a residential aged care facility (RACF) – these patients have a predetermined frailty status and will benefit from the GEDI service to provide a geriatric assessment, to fast track diagnostics, decision-making or rapid referral to a specialist geriatrician or surgeon/physician
• Frailty – ED clinicians will screen patients over 75 years using the CFS. This will help GEDI clinicians to identify frail older persons in the ED who will benefit from targeted assessment and specialised intervention.
• Referral from ED doctor or nurse – if any of the treating team request GEDI nurse involvement screening can be undertaken.

There are two types of patients for whom the GEDI team can extensively affect outcomes:

• Low acuity patients requiring a specific intervention such as wound care, urinary catheter replacement, or rapid diagnostic testing to confirm treatment plan. These patients may then be either rapidly returned to home/RACF or hospitalisation can be fast-tracked.
• Complex patients with deteriorating physical and cognitive functioning for whom this presentation may be a sign that additional care or support is going to be required in future. In these cases, more time spent on assessment and planning in the ED may prevent hospitalisation or re-presentation.

Focus on RACF patients

The GEDI team place the highest priority on RACF patients with the aim for a return to the RACF where appropriate. This is possible because the RACF has clinical staff that can provide care and monitoring. However, some RACFs may have difficulty in accessing newly prescribed medications out of hours, for example, and so the GEDI nurses will work collaboratively with the RACF to ensure continuity of care and safe transfer. Regardless of triage category, GEDI nurses can quickly identify and initiate interventions to enable faster ED processing. This selective targeting of RACF residents aims to reduce ED wait times for older patients who most often are assigned a lower priority triage category.

To facilitate rapid return to the RACF where appropriate, GEDI nurses communicate with the RACF staff to ensure ED staff have all relevant information from the RACF and/or GP. The information can include:

• The sequence of events prior to transfer
• Whether the GP has been involved or been notified of the transfer
• Any therapies, interventions or treatments that have occurred prior to transfer
• Whether contact has been made by RACF with the Next of Kin and/or Enduring Power of Attorney to ensure they are aware of the transfer
• Existence of Advance Health Directive/Statement of Choices on file with the RACF
• Baseline functional status to compare with the person’s current status
• Current medical history including medication list.

GEDI nurses will establish the goals of transfer with RACF staff, their ability to accept the care of the resident for discharge including recommended follow-up GP care or allied health intervention availability. This may include facilitation of medication for palliation or medical treatment e.g. antibiotics.

GEDI nurses must assist in ensuring a medical discharge letter accompanies all returning RACF patients and any newly prescribed medications are dispensed and returned with the resident to the RACF. The Emergency Department Discharge Medication Record (EDDMAR) can be used to prescribe new medications for the resident. These activities are aimed at circumventing problems for RACF staff in obtaining new medications and promotes continuity of care. View an example of a discharge checklist from a GEDI nurse.

Community patients seen by GEDI

Reasons patients living in the community are seen by GEDI:

1. When there are clear and early identification of need such as predetermined admission pathways (fractured neck of femur, palliative care or geriatrics, or interventions that may shorten ED LOS (provision of wound care, IDC placement, provision of analgesia, establishing goals of care.
2. When medical decision making may be uncertain and geriatric assessment may help to inform patient disposition. Individuals who do not have a clear, urgent medical indication for admission are the primary targets of the GEDI intervention.

Assessment

Assessment of patient – functioning both independently and interdependently the GEDI nurse can undertake rapid and targeted assessment of physical and cognitive functioning, as an extension to that undertaken by the primary care medical and nursing teams.

• The primary nurse will undertake the monitoring of vital signs, levels of consciousness and requirements for assistance with activities of daily living.
• The medical team will undertake a clinical history and order diagnostic tests.
• The GEDI nurse will add value to the assessment process by:
  • accessing information from a wide range of sources, such as: the patient, patient’s previous medical records, RACF, GP, family members and carers
  • accessing specific information related to end of life decision making and care planning
  • undertaking some of the activity required for medical diagnosis and decision making e.g. collecting a blood sample or undertaking an ECG
  • following up on delayed diagnostic test results
  • fast tracking access to more complex diagnostic testing e.g. x-ray
  • undertaking a delirium screen and further cognitive function tests and
  • identifying carer burden or responsibilities at home such as pets.

Older persons identified for the GEDI service receive a modified geriatric assessment utilising, but not limited to, validated risk assessment tools. This assessment may include the following domains:

• Presenting problem
• Patient goal of presentation
• Active and non-active medical problems
• Current medication
• Current activities of daily living i.e. bathing, dressing, eating, toileting, transferring
• Instrumental activities of daily living function i.e. cooking, shopping, transport, financial and medication management, telephone use
• Continence status
• Falls history
• Pain status
• Psychological function including cognition and mood
• Advance care planning arrangements
• Sensory information including vision, hearing, communication barriers
• Social/cultural functioning including available supports, current activities/interests, social history, community services, legal and financial issues, issues of domestic violence and suspected abuse.
• Carer status and carer stress/support issues, viewpoint.
  Clinical experience and judgement should also be used on all people who present who appear frail, regardless of being from an RACF, older age, or high complexity of needs resulting from an acute exacerbation of chronic disease (e.g. early onset dementia, heart/vascular disease, respiratory disease associated with immobility). This addresses the Commonwealth Aged Care Act 1997 (Amended to Act No. 99, 2013) philosophy which is not age specific but deals with people on a case by case basis.

A modified Comprehensive Geriatric Assessment (mCGA) has been developed to guide screening, assessment and the associated interventions to be provided by primary ED clinicians and GEDI clinicians to the older person. Following application of the CFS, the mCGA guides the multidisciplinary team working within the ED in actions that follow.

Decision making

Shared identification of issues

• The GEDI nurse uses a recognition primed decision-making framework (Klein, 1998) to determine whether the patient has particular geriatric syndromes that may interact with or be an underlying cause for this presentation;
• From the rapid and targeted assessment, the GEDI nurse identifies patient issues and formulates goals of treatment. This will be undertaken, where possible, with the patient, family and/or carers in support of shared or mutual decision making (Charles, Gafni & Whelan, 1997). This is a key function of the GEDI nurse. GEDI will access any available, previously determined advanced care plans of advanced health directives to ensure that they are followed and the patient is not subjected to unwanted treatments or procedures by the multidisciplinary team;
• In some circumstances the GEDI nurse will initiate actions or treatments independently, at this point (e.g. insert IDC, wound management);
• Direct referral for assessment to specialist medical or allied health professionals is also undertaken as appropriate at this point; and
• Throughout this process, the GEDI team communicates with the patient, their family members/carers and all members of the multidisciplinary team to facilitate combined progress planning. Shared decision making is then advocated for with the medical team (Charles, Gafni & Whelan, 1997).

Influence decision making and disposition planning

• GEDI nurses influence the range and scope of diagnostic testing. Using the primed decision making approach (Klein, 1998) and with reference to the goals of care that have now been established, GEDI nurses will discuss the utility of ordering some diagnostic tests with the treating medical team;
• They coordinate clinical decision making around further treatment and may have to act as the patient or carer advocate encouraging shared and mutual decision making (Frosch & Kaplan, 1999);
• The GEDI team can coordinate additional assessment by specialist medical or allied health professionals – depending on local ED pathways and relationships with other departments this can be undertaken by direct referral by the GEDI nurse. Particularly useful pathways include direct referral to a geriatrician for assessment or direct referral to physiotherapist to assess falls risk and likelihood of safe mobilisation post discharge;
• In collaboration with all the multidisciplinary team, GEDI nurses will influence disposition course. Sometimes junior medical officers will seek to admit an older person if diagnosis is unclear or safe return home cannot be achieved immediately. The GEDI nurse can provide additional information to the junior medical officer of possible solutions that may avoid an admission. For example, if a patient will be able to return home with additional community support, a GEDI nurse may suggest a stay in the SSU within the ED for a few hours while these community resources are put in place;
• GEDI nurses can also support the primary nurse to facilitate the processes involved in admission or discharge;
• Most importantly, having already established relationships with the patient, carers, family and other staff GEDI nurses will communicate and explain clinical and disposition decision-making; and
• Documentation of the GEDI assessment and communication is done in EDIS to enable easy access to the information for all medical staff. This information is then visible in “The Viewer” increasing the access to all hospital based clinicians and community GPs.

Disposition coordination

Once a shared decision has been made about what treatment the patient requires and what is the best environment for that treatment (i.e. hospital admission, transfer to another facility or discharge home) the GEDI team can assist the primary nurse in the following ways:

• Liaise with bed manager and medical team
• Liaise with and organises community support
• Organises additional specialist referral.

If the decision is to admit or transfer the patient to another healthcare facility the GEDI nurse can assist by:

• Liaising with primary RN and ward
• Informing patient
• Informing carers, family, RACF etc.
• Refer to inpatient teams using Patient Flow Manager (PFM).

PFM is a dashboard showing bed occupancy in all wards in the hospital and health service. PFM can also capture and display a CFS score to inform inpatient wards of a patients’ level of frailty. GEDI nurses identify the patient’s allied health referral requirements, high scores on risk assessment instruments and presence or absence of Advance Health Directive, before they have left the ED and enter these into PFM. These fields appear in red on the admitted ward’s dashboard so staff are alerted to the referral. This is then used by CHIP and Allied Health services to ensure early and proactive implementation of an appropriate plan of care. This inter-dependent function ensures that highlighted needs of the GEDI patient are addressed by the ward staff to ensure early intervention takes place.

If the decision is to discharge the patient home the GEDI nurse can assist by:

• Liaising with primary RN and RACF if appropriate
• Informing patient
• Informing carers, family, RACF etc.

Intervention – specific clinical interventions

As well as assisting the primary ED nurse and coordinating diagnosis and decision-making, GEDI nurses may instigate specific interventions for the older person. These include but are not limited to:

• Wound care
• Insertion or management of various devices e.g. peripheral intravenous catheters, urinary drainage catheters, percutaneous endoscopic gastrostomy tube etc.
• Urinalysis
• Blood collection.

NB: GEDI nurses also assist in activities that will directly assist in streamlining patient flow within the ED for GEDI patients i.e. organising transport home, inter-department movement of patients, ADLs - providing sustenance and assisting to the toilet when able. GEDI nurses will also provide support to primary nurses, particularly in times of increased workloads, to ensure the fundamental components of care are provided, as specified in attachment 1 of the mCGA guideline.

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