EDs are using 'GEMs' to improve elder care

2 years of specialized training required

Several EDs in the Canadian Province of Ontario have significantly improved their care for elderly patients with the introduction of a new position called the geriatric emergency management (GEM) nurse. These nurses have improved patient flow, reduced repeat visits, and lowered the rate of falls.

The nurses must obtain a clinical nursing specialty and often have at least two years of additional training in ED nursing and geriatric nursing.

"Our role incorporates case findings of high-risk elderly patients," explains Sonia del Castillo, RN, BSN, a GEM nurse at Toronto's Humber River Regional Hospital (HRRH). "We conduct a comprehensive geriatric assessment."

In addition, she says, GEM nurses also help the staff with admission decisions and patient advocacy.

When patients present and are assessed by ED doctors, says del Castillo, in the hectic ED environment there are times when not all pertinent information gets collected. "We talk to the patients and their families, as well as with the doctor and nurse, to identify the real problem and find out why they really came in," she explains. "We also collaborate with social workers in case of the need for crisis placement for high-risk geriatric patients.

Rakesh Kumar, MD, CCFP, chief of emergency services at HRRH, says, "This definitely improves the flow; the elderly get speedy and appropriate care. [After discharge,] they can be placed in the proper setting, be it at home, in long-term care, or chronic care."

Having the GEMs prevents repeat visits to EDs by helping to link them with primary care physicians, adds Kumar. "It also prevents admission into inpatient floors, which is one of the biggest things we've accomplished," he notes. Data show that from 2006 to 2007, elderly inpatient admissions dropped 38% — from fewer than 200 to fewer than 150.

Once the initial collaborative assessment is completed, if there is a medical problem the patient is treated by an ED doctor or internist. "As a GEM nurse, I am in charge of giving information to the family about all the help they can get if they go home," adds del Castillo. "I educate them and their family regarding geriatric issues and available community services to take advantage of so they can return to and be safe at home."

The GEM nurse can do more than simply help assess the patient's condition, Kumar says. "We make the initial assessment about whether they can go home, but the GEM nurse can help prevent premature discharge, and we then admit the patient," he explains.

At present, HRRH has one GEM on staff Monday through Friday from 8 a.m. to 4 p.m. "The hospital is trying to get a half-time nurse to cover weekends," notes del Castillo.