Saving elderly patients from the hazards of the ER
26:47 Share

1942, Europe. Soldiers find a boy surviving alone in the woods. They make him a member of Hitler's army. But what no one would know for decades, he was Jewish. Could a story so unbelievable be true? I'm Dan Goldberg. I'm from CBC's Personally. Toy Soldier. Available now wherever you get your podcasts. This is a CBC Podcast.

I'm Dr. Brian Goldman. This is White Coat Blackheart. For patients aged 75 and older, being admitted to hospital can be a preventable catastrophe. The longer they stay in hospital, the more deconditioned they get. Some lose so much strength and mobility, they can never go home, which is why I wanted to visit the ER at St. Mary's Hospital in Montreal. There, a special team is on the clock and on a mission to get older patients home before the bad stuff happens.

It's just after 7 a.m. at St. Mary's, and the team's unofficial captain is already here. Hi, my name is Julia Chabot. I'm a geriatrician, and I work at St. Mary's Hospital. Hi, my name is Lisa Paoloni. I'm a nurse clinician, and I work at St. Mary's Hospital. Lead the way. Should we begin with me? I'm the one who starts today. Okay, okay. Lisa Paoloni is a geriatric nurse with the geriatric ER team at St. Mary's.

They've been in place since November 2023. Lisa, a physiotherapist, a social worker, an occupational therapist, and one of four geriatricians. Today, it's Dr. Julia Shabbat. In the ER where I work, we have geriatric emergency nurses like Lisa. Our hospital also has geriatricians, but they don't see patients in the ER like Shabbat does.

What's different here at St. Mary's is how proactive Lisa and the team are in identifying patients in the ER who can go home through quick intervention, often the same day. So I start fairly early, around 7 o'clock, and I screen the system that we have that displays all of our patients inside the emergency department.

And what I'm screaming for is more specifically patients greater than 75 years of old who presents a geriatric profile and is in the emergency department with a geriatric syndrome, whether it's...

a fall, delirium, etc. We also screen for hip fractures in patients greater than 85 or with a certain frailty scale because then I inform the geriatricians and they do a pre-op delirium prevention. So there's a lot of screening for the geriatric patients in the emergency department. Why is it important for you to start so early? Just because

Sometimes we have a lot of consults and sometimes there's a lot of patients in the emergency that are greater than 75. So I have a lot of information to gather and a lot of screening to do. And when I present our cases at 8.30, I want to make sure that I have as much information as possible so that we can really start getting to work at 8.30 when we leave our meeting. Each morning, Lisa reviews information gleaned by ER nurses and doctors to prioritize the patients her team needs to see.

Lisa mentioned a frailty scale. That's the PRISMA-7. It's a standardized scoring system for frailty and autonomy, the capacity of the patient to manage on their own. On the board that we have in the emergency department, the patients that are, if they have a kind of a blue square over their name, it's an indication that their PRISMA score is greater than four. And those are typically the patients that I will kind of screen throughout the day because those are patients that are more frail and at risk of a functional decline.

You're especially keeping your eye on them. Exactly, exactly. I kind of do a screening to see if they would benefit from any member of the MDT. One of the things that we try to do is we try to get them out of the emergency department as soon as possible. We don't want them just lying in a stretcher, sometimes in a hallway. So that's it. That's one of the reasons why we try to start so early. We're trying to decrease the amount of time that they're in the emergency department. And you have a personal stake in this because of your grandparents. Yes. Tell me about that.

My grandparents actually helped raise me. How many people who gravitate to geriatrics have been around? It's normal for them to be around people who are older and they respect them and love them and see them as not having deficits but having strengths? So that's it. And in geriatrics, it should be a strength-based approach. Sometimes it's very deficit-oriented. And I don't see that in my grandparents who helped raise me. And they're 85 years old and they're still the strongest people that I know.

And sometimes I even need them to still take care of me. You know what I mean? And they're 85 years old and I don't look at them as weak or frail or incapable. Keeping patients from becoming even more frail from a preventable stay in hospital is paramount to the team, says geriatrician Dr. Julia Shabbat.

We want to try to prevent all what we call iatrogenic complications, all of the complications that can happen in the emergency department. So it's not rare that if you have an 85 years old, for example, who has cognitive issues,

They spend a night in the emergency department on a stretcher. They don't get a very good night of sleep. And the next day, they're a little bit more confused and they are in what we call delirium. And then we're not going to be able to discharge them home. They're going to need to be hospitalized. We really want to try to avoid that as much as possible. So if we can save them...

time in the emergency department and hopefully send them back home or send them back to the residence where they live. This is really one of the goals of the team. And having seen it, and you know that I'm an eMERGE physician, so that it doesn't take more than a few hours. If I see a patient that I've referred to the internal medicine team yesterday and I come back the next day, I often find that they're more confused than they were the day before. And I think, you know, when I was in training, I used to think the safest thing to do is to admit patients.

But sometimes what you realize with geriatric medicine is that this may not be actually the best thing to do for the patients because just keeping them here may lead to complications. And I'm just talking about delirium, but there's also all of the deconditioning. So we know that spending one day in a stretcher or in a bed for an older adult...

The rule of thumb is it will take them three days to be able to recover just in terms of muscle loss and being able to go back to their mobility. The emergency department is just not an ideal environment for the elderly population. And Dr. Shabat a lot of times says, you know, we have a very small window sometimes before the patient starts to get delirious or a fall happens in the emergency department. How small is the window as you see it? Often I would say it's a couple of hours. Wow.

And this is why for us it was so important to be able to screen and to identify those patients so that we can start to work on a plan as soon as possible. Good morning. Good morning.

This is our physiotherapist, Natalie Ilianko. Hi, Natalie. Nice to meet you. So the team is gathering. Yes. So me and Natalie, we usually touch base in the morning before the emergency sign-over, and we kind of take a look at the consult, so the geriatric consult, and we kind of discuss the case and see, oh, do we need to get an OT involved? Do I need to be involved as a nurse? Where is this patient from? If the patient comes from a residence with nursing care,

Usually I'll do a report from the residents so the patient has a safe transition back to the residence, communicate with them anything that happened in the emergency. So we kind of come up with a plan right away, even before the emergency sign-over. So everything ready? And we're going to sign over. We're going to be doing the emergency part of this. During sign-over, they talk about all the patients in the emergency department.

Yes. Me and Nat will sometimes chime in and give extra information about the patient that might be useful for the emergency department. And we also see this patient kind of sounds appropriate for the multidisciplinary jury team. Is there anything that we could help with? Yeah. Hello. Good morning. Good morning. Hi. Hi.

Sorry to have a microphone here. No, that's okay. The night doctor hands over patients to the ER physicians and nurses on the day shift. What's new to me as an ER colleague is having the geriatric team right there scoping out the older patients who arrived overnight. Hi, my name is Dr. Elise Papillon. I'm an emergency room physician at St. Mary's. Do you like working nights? I love nights.

Same here. Hi, my name's Rob Drummond. I'm an emergency physician at St. Mary's Hospital, and I've been here for 30 years now. Trauma 1. Okay, so trauma 1 is a 37-year-old lady. The first patient Dr. Papillon hands over is 37, but many of the other patients are right in the geriatric team's wheelhouse. Someone admitted him to geriatrics. L4 fracture. L4 fracture. Significant pain, so Jerry admitted yesterday. Yeah, so he's a 75-year-old guy who's here with recurrent falls over the last week. Okay.

77-year-old lady recently discharged from Catherine Boo. She has a proximal multi-part humerus fracture. After the handover, I chat with Dr. Rob Drummond, the ER physician on duty today. He's been here since long before the days of the geriatric emergency team. As an emergency physician like me, what are your greatest concerns about older patients in the emergency department? It's not...

a mere inconvenience for them. It represents a greater risk for morbidity and mortality. Studies have shown this over and over again. You have a little old lady who's parked in an emergency department, you know, without benefit of sunlight,

clocks, etc. And if they weren't delirious beforehand, they're going to be delirious after, and delirium kills old people. Lisa briefly mentioned delirium, or sudden change in a senior's mental state. Common causes include a fall with a head injury, a bladder infection, or even dehydration. Patients with delirium can't go home until it resolves. I wanted to hear more from Dr. Drummond.

What's it been like having the team? I rely on them. I think they rely and trust me. But it's made a huge difference. Like, it really does. Like, they're very proactive. And, you know, I might be like, oh, you know, this patient just checked the x-ray and sent something home. But I'm like, whoa, whoa, whoa, where do they live? What kind of residence exactly? That residence you think is full care, but it's not. It's a semi-autonomous residence or there's no services. So they know the players in the system.

They really are punching outside their weight category. So you know the general things that need to happen, the general headings, but they know the details. 100%. Push comes to shove. I can see all these patients, but I won't be able to necessarily understand all the nuances that are involved in their care as well as I do without their input. And the nuances are kind of everything. When you're talking about elderly patients, 100%.

Thank you for speaking with me. You're very welcome. Thank you very much. So what's next? So we go to our meeting now between the geriatric MDT team. And it's starting right now? It's starting now. Okay, so we got to go. Okay. Yeah, so this is like our geriatric multidisciplinary team, which is where we meet. Good morning. Everyone will start trickling in. Come on in. So I will take off.

Okay, so we have our bed D which is the one that we admitted from yesterday with the new L4 fracture and back pain. The handover meeting helped the team home in on which patients to assess. Now they develop an action plan for each patient.

all before 9 a.m. They work against the clock to give patients the best chance to be able to go home. Patients like the 84-year-old woman we're about to meet. She has bursitis in her hip made worse by a recent fall, plus a deep vein thrombosis, a blood clot in her leg. Can you give me your first and last name?

Maria Pastore. So how's your pain here when you're not moving? My leg? Yes, it is. If I lie down, it's okay. Okay. Not all the time. Okay. We had introduced ourselves, but I'll do it again. So I'm Natalie from physiotherapy. Nice to meet you. Hi, I'm Stephanie from occupational therapy. Hi. So you're in a residence and you normally walk with a cane, but you had a fall two weeks ago and now your hip pain is worse. Oh,

Okay, so we'll see how you are. Rheumatology will see you later for the hip, but we'll see if you can move and hopefully we can send you home maybe with some extra help. Yeah, she explained to me already. Okay. Can I ask how did you fall?

I just do fast, too much fast. And I fall out on the floor. Physiotherapist Natalie Ilianko and occupational therapist Stephanie Young learn that Maria has recently been to two different Montreal ERs.

At the first, she got a cortisone shot for the hip bursitis. And when you fell this time, you were at Maison Rosemont and they just sent you home, yes? Yes, they gave me nothing, just a paper to buy a Marchetta. Marchetta is Italian for a walker. The doctor has to prescribe it. Maria says she was given a prescription for one, but no one made sure she got it.

And you're independent. You take, you get dressed by yourself. Yes. You take a shower by yourself. I cook. You cook. And who does the housekeeping? Me. Oh my, you're doing everything. Yeah. Okay. So I'm just going to quickly see how you move your arms and your legs, okay? Okay. Can you do this? Yes. Good. Natalie checks Maria's physical strength and range of motion. Very strong. Yes, so it's swollen. Yeah. Okay. Okay.

Do you feel okay to walk a little bit? With that? I never did before. That's the first time. Today is the first day. The team gives Maria a walker, teaches her how to use it and adjusts it so it's right for her. Oh yeah, much better. Keep the walker. Hold on to the walker.

Oh, you're fast. You don't have to run. They get Maria to sit upright, an important step to see if it's safe for her to go home. One thing just to make life difficult. Can you stand up from this chair?

If I can stand up with the legs? Yes, you can push from the armrest. Just I want to see if you can stand up. Yeah, okay. If the chair doesn't move on the floor, yeah. Okay, alright, perfect. Have a seat. So you think you'll be able to manage at home if we give you a walker? Yeah. Yeah, so I'll be back later. Yeah, I'll be back later with a walker for you, and we'll go from there. Thank you very much for everything. Thank you. You're welcome. I appreciate it.

You did well. We'll figure it out. We'll figure it out. We'll be right back.

I'm Katie Boland. And I'm Emily Hampshire, who didn't want to be here. On our new podcast, The Whisper Network, we want to speak out loud about all the stuff that we usually just whisper about, like our bodies, our cycles, our sex lives. Basically everything I text to you, Katie. So this is like your intimate group chat with your friends. And we can't wait to bring you into The Whisper Network. This journey is a nightmare for me. I'm doing it for all of us. So you're welcome.

You're listening to White Coat Blackheart. This week, how the geriatric emergency team at St. Mary's Hospital in Montreal works proactively to see older patients in the ER and, if possible, send them home safely. The 1,100 patients they've assessed have spent on average 10.5 fewer hours in the ER. And they've cut the number of older patients admitted to hospital by 28%. Good for the patients and good for the hospital.

Dr. Julia Chabot says the implications are huge. We see that the population is aging and we see more older adults coming in the emergency department. We noticed that our numbers were going up and up and up in the last few years and at the same time our resources are not going up and up and up. We're not creating more geriatric beds on the ward and we were noticing that there was a significant portion of patients that we would see in the emergency department that

Without a team, we were not able to help. And we wanted to create that team so that we would be able to do the prise en charge and start to take care of patients the minute they would come in the emergency department. So what's new and different and special about this team compared to some of the other teams that you're aware of that you've looked at? The way that we organize ourselves.

We don't necessarily assess patients as a whole team. For me, it's so important to see if my patient is going to be able to ambulate or not. So I will go with the physiotherapist during her assessment.

But at the same time, if I don't need to be involved in a case, and if only the physiotherapist needs to be involved, I may not get involved. So this is one of the first thing that was very, very important for us. The second thing is the whole screening that you saw this morning, where Lisa comes in, she's very, very proactive. She'll try to find out based on age, based on PRISMA score, based on different criteria, based on the sign over, based on informal discussion, having this screening, because we really wanted to make sure to catch as many patients as possible.

And the third thing is that we have a geriatric assessment unit here so we can admit patients. And this is not the case at every single hospital. Not every hospital, unfortunately, has a geriatric assessment unit. It is very easy for us to assess a patient. And if we say this patient needs an admission, then I admit the patient in my beds on the geriatric assessment unit.

As an emergency physician, I'm quite familiar with the potential harm of being admitted to hospital and what that can have on older patients. For people who are listening to this for the first time, what kinds of side effects are you trying to prevent?

Probably the most common one that we see is delirium. So especially if somebody has some cognitive issues and you bring them in an unfamiliar environment, give them pain medication, and sometimes we give a dose maybe that's a little bit too high for what they should need, and they get confused. So this delirium, this confusion is one of the main things that we try to avoid. And how can we try to avoid that? Trying for them to spend...

as less time as possible in the emergency department, trying to make them ambulate, trying to make sure that their pain is well controlled, trying to make sure that their medications are also well adjusted, that we're giving them the right doses, trying to make sure that they're not going to be constipated. You know, we often forget about that. Constipation can lead to delirium. It definitely can lead to delirium. So that's one of the things that we try to really, really look into.

We also focus on mobility. We don't want patients to lose their mobility when they come to the emergency department, trying to ambulate them, to walk with them as much as possible so that they don't decondition. And it begins right at triage, doesn't it? From the moment the patient appears either by ambulance or has been brought in. Tell me about that. I think this is one of the lessons I heard during my residency training. There was an internist who would always tell us,

Your discharge planning starts the minute that the patient is getting in the emergency department. We developed that team to have a proactive approach. We don't want to wait until somebody consults us. We don't want to lose a day. We don't want to lose any hours. We often have a small window of opportunity in the geriatric population and we certainly do not want to lose that window of opportunity. And in the olden days, all of them might have been admitted? In the olden days,

It was almost an exception when I was able to discharge a patient because I didn't have the support of the team. My dream is I really hope that people will be jealous of our model and will want to copy it. This is one of the dreams. We need to do more with less.

And I think this is a good model where we're actually able to do more with less because we are avoiding hospital admissions. So when you say less, you mean avoiding a hospital admission. Exactly. To that point, how much money do you save? If we consider that a geriatric admission is probably about three weeks,

That's our average length of stay. So it's something like $30,000 to $35,000 of the cost of a hospital admission. So for every avoided admission, we're probably saving around that cost of money. So you can imagine that

The investment with the team is not so... It's actually a beautiful investment because we end up being able to save a lot of money. Several million dollars just based on the last year alone. And on top of that, I mean, beyond talking about money, we're providing the care that the patients want. Last question I'm going to ask you because I'm thinking about caregivers, loved ones, family caregivers. I was a family caregiver for my parents, for my sister.

And I know that from time to time, they think when their loved one is in the emergency department, they can relax because their loved one is being taken care of and they can relax. And that tells us, you know, so sometimes it's not just the patient, but their loved one who's undergoing stress. Have you thought about what to do for them?

So we're constantly in contact with caregivers in our evaluation. Every time, I think getting collateral information, understanding the home situation is extremely, extremely important.

And I often say, you know, there's the patient, we have the multidisciplinary team, but the caregivers are definitely part of the evaluation and they're definitely part of the assessment. And when we organize, let's say, a discharge, we need to make sure that the caregiver agrees to that plan and we need to make sure that the caregiver will also be supported in that plan. And we have to take that into consideration because we will sometimes admit patients to the hospital because of caregiver burnout, because the caregiver's

need more resources, need time and need to recover. So this is sometimes a reason why we will keep patients in the hospital as much as we will try to discharge patients as much as possible. There are cases like this sometimes that this is what the caregiver will need.

Sometimes we will see caregivers coming in, they're burnt out, and then what we discover is that they have no support at home. But it definitely has to be a part of the evaluation. Dr. Chabot goes to see Maria Pastore so she can do her part of Maria's careful evaluation.

We're going to be able to give her a walker before she leaves. And I think that's the biggest difference with the previous emergency department visits that she had, is that if she's being told you need to use a walker, our physiotherapist will give her a walker. One last detail to work out before Maria can go home.

She needs a family doctor she can visit easily given her mobility issues. So Lisa is actually calling the residents right now because we believe there may be a family physician at the residence to see if her care could be taken over. We're also going to organize, she needs a rheumatology, follow-up hematology, so rheumatology for the joints and hematology for the blood doctor. We just want to make sure that

All of this care is going to be coordinated so that when she leaves the emergency department, we have a solid plan and that she knows where to go from there. And part of it is not just getting her home, but making sure she doesn't bounce back. Exactly. This is a population that tends to bounce back the more often, unfortunately. Bounce back, meaning they come back to the emergency department very quickly after they were sent home. Exactly, exactly. It takes the investment of having the team, but once you have the team, once you invest that, you're actually going to save at multiple other places.

And the problem is that if we just look at things in a silo, patients are not static, their conditions are not static. There's the community care, there's the emergency department, there's the hospital care. And I think if we can demonstrate...

More of that continuity, I think we're going to be able to prove that our intervention is definitely working. Nurse Lisa Paoloni comes over with a clipboard and reviews what they've done for Maria. Okay, perfect. So we have a rheumatology follow-up. We have a hematology follow-up. We have a family physician that is going to now follow her at the residence. And Nat will give her a walker. Okay.

She needs the follow-up otherwise she's going to keep ending up in different ERs throughout the city. If you did nothing else but get her primary care that would be a massive accomplishment. So I think this was a success. It was one of our discharge that we're very proud of. Okay, Mrs. Pastore. Yes?

This will be your walker that you take home. No, no, that's from the ER. I'm giving you one that's brand new that will belong to you. I put your name on it. Okay, great. I just need you to stand up so I can measure the height for it. How much I hold you? Nothing. It's covered by the Ram Q. Okay, thank you. Okay? And I'm going to go speak to the nurse now to give you some pain medication, okay?

Thank you very much, I appreciate it. God bless you all. All the world. I'll fax it because I want them to be aware but I'm going to give you a copy for you to go home. Thank you very much.

Lisa gives Maria some pain medication. As she speaks with Maria in her mother tongue,

I can imagine Lisa speaking with her own grandparents. In less than 24 hours Maria has a new family doctor, pain medication, a walker and follow-up appointments with specialists. All while avoiding a stay in hospital.

As a whole team, I think this was a great intervention. She looks steadier. Amazing. Wonderful. A triumph of teamwork ERs across Canada can learn a lot from. All the best to you. That is amazing. White Coat Black Art was produced this week by Jennifer Warren with help from Stephanie Dubois and Samir Chabra.

Head to cbc.ca slash whitecoat for Jennifer's fantastic article about geriatric ER care with my photos of the team in action. Our digital producer is Ruby Buiza. Our senior producer is Colleen Ross. Special thanks to our CBC colleague Danilo Fiorenzano for helping us with Lisa and Maria's Italian. I'm Brian Goldman, and I'm proud to bring you medicine from the Canadian side of the gurney. See you next week.

For more CBC Podcasts, go to cbc.ca slash podcasts.