The Juravinsky Hospital and Cancer Centre is an academic teaching hospital, and one of the seven hospitals in the Hamilton Health Sciences family of hospitals. Emergency Services at the Juravinsky Hospital provides acute care for both adults and children, however of all the Hamilton Health Sciences ED’s Juravinsky’s has the highest percentage and absolute volume of patients aged 65 and older. As well, those over 65 account for two thirds of total hospital admissions with longer length of stay (for both admitted and non-admitted) of these patients. Finally, patient and family experience themes demonstrate an opportunity for improvement.
Ace Quality Improvement Team
The team consists of eight individuals:
- Dr Amy McCulloh – Emergency Medicine, site lead
- Dr Brian Misiaszek – Chief of Geriatric Medicine
- Tammy Walker – Clinical Manager in the ED
- Donna Marttunen – GEM nurse (joined the team in September 2016, some time after this ACE initiative started)
- Jennifer Kodis (Director of seniors)
- Shollet Burke (social worker)
The team formulated the ultimate goal of reducing the admissions for patients over the age of 65 years by 10% (from 38% in 2014/2015 to 34%) by March 2017.
In order to achieve this amazing objective (which relates to the idea of the ED becoming the “front porch” instead of the “front door”), they introduced:
- AUA (Assessment Urgency Algorithm) high-risk screening tool to be used at primary nursing assessment for all patients 65 years of age and older. The target is that 95% of patients aged 65+ will be screened on arrival
- GEM nurse, who was hired and started in September 2016. The target is that the GEM nurse will see 75% of patients with a score 5-6 on AUA
- Staff education program: All staff are to complete the Geriatric Emergency Medicine online educational program
Additional activities included the introduction of volunteers into the ED to reduce risk of delirium/deconditioning and a review of the physical plant of the ED based on the Senior-friendly hospital guidelines.
The team also implemented a survey among Physician and ED staff. Interestingly, both groups were confident in their knowledge and skills of geriatric care, but felt that their ED needed improvement in order to achieve better senior care. Major themes noted were the need of better equipment, improvements in physical environment and protocols (e.g. improved medication reconciliation, concrete discharge and follow up plans, contingency/back-up plans) to ensure safe care for the patients.
The team promoted staff engagement by ensuring staff were involved and encouraged to take ownership of improvement activities through:
- Daily Huddles
- Unit level quality council
- Front line staff involvement and planning
- Regular item on physician and staff agendas
Patients and families were involved in co-design of care through patient and family focus groups, and weekly leadership interviews with patients and family.
Communication and perseverance is the key of success because change is tough and nothing goes as planned!