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9.4 What Does Ideal CGA in the ED Look Like?
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whilst therapists would not need to know the detailed intricacies of the manage- ment of acute heart failure, it is important that they know that intravenous diuret- ics might be required for the first few days that will result in polyuria and then be able to incorporate continence needs into the rehabilitation plan. Equally, doctors will need to appreciate that just because a patient has grade 5 power on the MRC grading system, this does not necessarily translate into useful func- tional ability.
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9.4.2 Patient Centred
Person-centred care (PCC) attempts to respect the person as an individual, with a history (biography), values, preferences and the right to make choices [50]. This aims to enhance engagement and enjoyment of life, preserve abilities and avoid or diffuse distress.
Consider a frail older person attending an ED with chest pain. A common approach for people with chest pain is to undertake a rapid assessment, initiate tests that will stratify cardiac risk and then discharge with reassurance that the chest pain is not cardiac. For patients who have attended and worried they might have heart conditions, this might be helpful. Protocols can be prepared that can automate much of this process, resulting in a rapid, efficient and possibly effective service, for some.
But such an approach is not so useful for frail older people, in whom the range of conditions that might present with chest pain is broad. It is important to evaluate the pain in a broader context, which can really only be addressed by undertaking multi- dimensional assessment. This might then reveal that actually the pain is resulting from shoulder arthritis that has flared up because the person has forgotten to take their pain killers because of worsening, hitherto undiagnosed cognitive impairment.
The solution here is not then the reassurance that the pain is not cardiac but a referral to the memory service and to organise supervision of medication. So this is individu- alised care, tailored to the person based on an understanding of a range of factors.
Person-centred care also respects individual preferences and choices—so, for example, the refusal of ongoing investigation for apparently severe conditions as the individual prefers quality to quantity of life. Put very simply person-centred care is about treating the person, not simply following a condition-specific protocol.
Whilst all patients will want to receive patient-centred care, it is even more important for older people with frailty, who will have a number of comorbidities, which means that a traditional disease-orientated approach may not be effective and may be dangerous.
9.4.3 Patient Identification
The ideal ED will routinely risk stratify their population based on frailty (needs), as well as specific conditions (diseases). They might use a simple scale, which is valid and easy to complete, such as the Clinical Frailty Scale (see above). The frailty identification might be undertaken by the prehospital service and be part of the handover, or it will be part of the handover assessment process carried out alongside the early warning score. Automated tracking systems will alert care providers to the presence of frailty, which in turn will trigger a different model of care.
9.4.4 Multidimensional Assessment
All urgent care staff will possess the basic competencies necessary to initiate a mul- tidimensional assessment (CGA), supported by easily accessible e-learning plat- forms and/or clinical navigation toolkits. Geriatric teams will be embedded at key interfaces on the patient pathway, supporting urgent care staff in the more difficult scenarios, through role modelling and some direct clinical care.
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9.4.5 Development of a Coordinated and Integrated Plan for Treatment
CGA usually gives a lot of information that needs prioritisation by developing a stratified problem list—which will be informed by the multiple domains described above. The care plan should be an individual plan for each patient and is preferably discussed with all healthcare workers, the patient and informal caregivers involved in the care for the patient.
As the ED plays an important role in the screening and identification of prob- lems, an important part of the further planning will be referral to other services in and outside the hospital, e.g. referral to memory clinic, falls clinic, CGA unit and primary care provider.
Having an overall picture of the older patient in the ED through geriatric assessment can enhance the decision-making process with regard to orientation of the patient (admission or discharge) and may impact indirectly patient flow in the ED. An admission to the hospital can be avoided and replaced by a safe discharge or alternatives to admission (day hospital) or hospital at home services [19, 20, 46–51].
Standardised communication systems will allow the generation and case man- agement of stratified problem lists which are multidimensional in nature and focus upon patient-centred goals of care.
9.4.6 Reducing Iatrogenesis
ED staff will be aware of the harms of common procedures, such as urinary cathe- terisation, and will think twice about undertaking such a procedure without robust justification in older people identified as being frail.
ED staff will have access to scales such as the STOPP-START tool and the Anticholinergic Burden Scale which will allow them to confidently rationalise med- ication in the ED setting, in some case precluding the need for admission. They will be aware of the importance of communicating and change back to the primary care practitioner for ongoing monitoring.
Consideration will be given to the appropriateness of investigations that carry a risk of harm, for example, contrast-enhanced CT scans, in people who are severely frail, as to whether or not investigation will add to quality of life.
9.4.7 Early Discharge Planning
Careful consideration will be given to the relative risks and benefits of treatment in hospital or at home. ED staff will be aware of the risks of hospital-associated harms and will weigh admission for investigation and management up against care at home. If home is deemed an appropriate option, after discussion with the patient and family, then the stratified problems list, the initial output of the CGA, will be communicated to the primary care practitioner and community teams to direct ongoing care. The ED staff will be aware that the ED itself is not an ideal setting to
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undertake a detailed assessment and so will communicate the urgent and important issues first, so that the community team can address any outstanding issues. The ED staff will be aware of the risk of readmission as they will have received real-time data from the IT systems that indicate the risk of readmission based upon locally run algorithms derived from the Clinical Frailty Scale. The ED team will identify which issues are most likely to contribute to readmission and prioritise these accordingly.
For example, if an individual attends the ED with a fall, then it is probable that a future readmission will be related to falls or mobility, and hence an early referral to community therapy or a falls prevention service, alongside consideration of bone protection, will be helpful.
9.4.8 Follow-Up
The coordination of referrals and coordination of implementation of recommenda- tions will improve the chance of a successful discharge.
The ED staff will routinely ask if there is a case manager already involved in the patient’s care and ensure that they received a copy of the ED summary if being dis- charged or that it is highlighted to the inpatient care team for those being admitted.