35 GERIATRIC EMERGENCY MEDICINE (GEM)’ PEARLS AND PITFALLS’- AN INTERDISCIPLINARY APPROACH TO EDUCATION

Background

In recent years we have seen increased awareness of the terms ‘frailty’ and ‘GEM’ in many of our Emergency Departments (ED). A clear understanding of these terms within the context of ED is essential to provide a holistic care and to best meet the needs of older adults. It has been highlighted internationally that current training programmes do not sufficiently address learning needs of trainees to optimise care of this cohort of patients. The European Geriatric Medicine Society and the European Society for Emergency Medicine has attempted to address this gap through the introduction of a core GEM curriculum in 2016, however, at a local level many EDs are not utilising this resource for a number of reasons including lack of awareness and prioritisation of other local learning needs as determined by specialist training. To address the GEM learning needs at a local level an initiative idea was trialled in the form of a GEM teaching wall with dedicated monthly topics chosen from the above curriculum.

Methods

The initiative was led by a Senior Physiotherapist working on the Frailty Intervention Therapy Team and a Senior House Officer (SHO) working in ED with collaboration from other ED members as identified. A brainstorming session took place to identify potential topics. A poster was created by the project leads each month focusing on a core topic including an overview on the subject, national/international guidelines and top tips how to best manage in ED. Relevant team members contributed to different topics. Monthly posters were displayed in the ED.

Results

The project has been successfully running for 4 months with topics including Abdominal pain, Silver trauma Delirium and Falls.

Conclusion

GEM teaching is a cornerstone of successful management of older adults presenting to our EDs. Novel MDT teaching approaches can address the identified learning gap in this area and highlight international recommendations with minimum cost.

49 ASSESSING EFFECTIVENESS OF AN OUTREACH VISIT PATHWAY FROM ED & REQUIRING FURTHER FOLLOW UP IN THEIR OWN ENVIRONMENT

Background

Falls are a leading cause of presentation to the Emergency Department for older adults. They often are at higher risk of admission to hospital which can lead to other complications of frailty such as development of delirium or deconditioning. The risks of admission were further complicated in the past year due to COVID and its adverse outcomes on our older frail population which further highlighted the need to manage their needs at home where possible.

These above changes have led to FITT reviewing the scope of our outreach service with a focus not just on facilitating discharge but preventing further presentation or deconditioning.

Methods

The aim of the project was to identify appropriate FITT patients to provide an Outreach visit from ED within 72 hours of discharge pending needs. This service was in conjunction with the existing Integrated Care Teams/community services but an outreach visit direct from ED may have been indicated due to; staffing levels, response time, catchment area or existing rapport with the individual patient. This was pending staffing levels with reconfiguration of existing staff to support the outreach therapist.

Appropriate patients included.

-Recurrent falls.

-Unresolved delirium/advanced dementia with ongoing therapy needs.—Bridging gap while awaiting community teams.

-Equipment provision.

Results

Over 10 months 34 outreach visits completed.

Average CFS: 6.

Reasons for: 

12 for safety checks.

15 equipment provision/fitting.

6 mobility reviews.

Onward referrals: 

22 (PCCC OT, Physio, PHN & day hospital & ICT).

Represent within 7 days = 0.

Represent within 30 day = 14 (41%).

Conclusion

The provision of an outreach services allowed a swift therapy review in the patient’s own home & onwards referrals as indicated. Often these patients were likely to be admitted however the outreach provided a safety net to facilitate direct discharge from the ED with no representations within the first 7 days.

50 A COMPARISON OF FRAILTY SCREENING TOOLS WITHIN THE EMERGENCY DEPARTMENT

Background

Increased awareness has been given to the value of identifying frail for risk stratification and to assist in providing frailty attuned care rather than disease specific input.

This increased awareness both nationally and internationally has led to many ED’s introducing the Clinical Frailty Scale (CFS) to triage however as a service we wanted to evaluate which tool would best meet our needs to screen appropriate patients and highlight the current level of frailty within the Emergency Department.

Methods

Over a 3 day period all patients over 75 who present during core hours were screened by a senior FITT member using a number of frailty tools (CFS, THINK frail, InterRai, PRIMSA 7 & compared against our own clinical reasoning if a FITT assessment was indicated).

Results

Total Patient’s over 75 screened by screener & FITT—48.

Average age: 82.

Sex: 51.62% male.

Discharges: 57% d/c’d.

Average CFS (Screener) = 5.

Average CFS (FITT) = 5.

28/48 CFS same = 58.33%.

15/48 CFS differ by 1 point = 31.25%.

Average THINK Frail (Screener): 3. 

Average THINK Frail (FITT): 2. 

17/47 THINK Frail same =36%.

21/47 THINK Frail differ by 1 point = 44%.

80.85% same or within 1 point difference.

Conclusion

The CFS score provided the most consistent when comparing scores by multiple disciplines/grades.

Although the majority of older adults who scored a CFS of 1–3 or deemed non frail at triage were unlikely to benefit from a CGA, those who presented with a new fall often did require FITT input.

This research has led us to move away from our current triage tool of THINK FRAIL to the CFS, whilst continuing to assess any new falls irrespective of score.

51 TO EXPLORE EMERGENCY MEDICINE SPRS UNDERSTANDING, IDENTIFICATION AND MANAGEMENT OF FRAILTY WITHIN THE EMERGENCY DEPARTMENT

Background

Our frail cohort of older adults represent a large proportion of those presenting to our Emergency Departments. This has led to the introduction of diverse teams in many Emergency Departments to support their complex care needs. However, it is not known if Emergency Clinicians have a clear understanding of frailty identification and management or feel this is part of their own role.

The aim of this study was to engage with Emergency Medicine Senior Trainees on the national training scheme in Ireland to explore their understanding of frailty and what they feel their role is in its identification and management.

Methods

Following a literature review based on defined criteria, a number of focus groups were held with ED PGY4 and above doctors working in various Emergency Departments throughout the country, with thematic analysis of the transcripts of the focus groups.

Results

In total, 13 Emergency Medicine PGY4 and above doctors partook in the focus groups with an overall view that frailty identification was part of their role within the Emergency Department; however there was agreement they have limited insight into the core principles of frailty identification and management. There was also an overall desire for future formal education on frailty to be provided. Three themes in the form of frailty recognition and assessment, education on frailty, and the role of the multidisciplinary team were identified as well as a number of subthemes for further exploration.

Conclusion

The consequences of frailty often lead to presentation to the Emergency Department. There is an increased awareness of its presentation but the core providers of emergency care feel there is a lack of the education required for them to manage the consequences of frailty which they encounter on daily basis and they have a clear desire to increase the knowledge base and skill set.