A GEM of an idea

The Tan Tock Seng Hospital (TTSH) in Singapore first started a Geriatric Emergency Medicine (GEM) in 2006. Since that time, the hospital has introduced several initiatives with the aim of improving the delivery of care to elderly patients in the Emergency Department (ED) including risk stratification, geriatric screening, falls evaluation and bladder control. TTSH currently has four GEM subspecialist doctors, and have trained more than 50 GEM nurses in its ED. TTSH remains the only hospital with geriatric services in the ED.

Ageless Voice finds out more about GEM from Dr Foo Chik Loon from the TTSH Emergency Dept:

What’s GEM about? How did you become involved in this field of emergency medicine?

In 2006, when at a lull in my career, my head of department pulled me into her office and asked me to start a geriatric emergency service. I had no interest in the elderly then, but later came to be in awe of every geriatrician I’d met. Today, with the help of an amazing team of doctors and nurses, slowly but surely, we’ve helped a lot of ED elders.

GEM is about improving the delivery of care to the elderly patients presenting to the emergency department. Its three pillars are:

a) Education – Majority of ED doctors and nurses received minimal training in geriatric care in medical/nursing school. It is important to raise their knowledge of the unique characteristics of the elderly, such as atypical presentations, polypharmacy, cognitive impairment, chronic diseases, and psychosocial dysfunction.

b) Target & screening – The ED traditional model of care is to ‘see and dispose’, i.e. to manage the patient’s primary complaint and either admit or discharge. However, the elderly patient is far more complex than their younger counterparts. Apart from the primary complaint, there are often multiple biopsychosocial issues that are hidden, that may have contributed to the presenting complaint, and that would result in further adverse events if unaddressed. The role of GEM is to screen for and unravel these unmet needs.

c) Networking – If clinically possible, elderly patients should be kept away from hospitalisation as far as possible. Admission comes with risks of deconditioning, nosocomial infections, medication errors, etc. To provide alternatives to admission, it is necessary for ED to establish direct workflows and links social, community and stepdown services. This is currently lacking in most EDs, resulting in inadequate transition of care upon discharge from ED.

Dr Foo Chik Loon from the TTSH Emergency Dept.

Fitting GEM into a busy ED requires a change in culture and mindset from ED staff at all levels. The stereotypical ED doctor and nurse need to adapt to the slower pace of geriatric screening and assessments. Three issues come to mind:

a. Even in a busy ED, GEM screening works. It has shown to significantly reduce ED re-attendances, hospitalisations, and functional decline.

b. A new ‘GEM nurse’ role is required. The GEM nurse performs all geriatric-related duties, and needs to be protected from the constant distraction of other ED demands.

c. A quarter of our ED attendance is 65-years-and-above. The GEM nurse has become a necessity rather than a luxury – as necessary as a triage or a resuscitation nurse.

What have you learnt from this programme?

I’ve learnt that little things matter. Small improvements in the elderly patient lead to significant satisfaction and functional improvement. There is no magic wand here, and we are not trying to reverse ageing. We’ve seen elderly patients well up with tears simply because we’ve asked them a question about their mood – something they’ve never been asked.

Share with us one success story from your current programme.

Just the other day, an elderly came to our ED for a fall. She had a fall a few days ago, had been admitted, and an MRI showed fractures of her right pubic ramus (a part of the pelvis). She was able to walk upon discharge from the ward. When she reached home, she tried to change her trousers and fell again, this time fracturing her left hip. She may never walk again. It makes me wonder if the hospital system had failed her by not allowing a longer period of rehabilitation after her first injury, or by not having a community nurse accompany her home to evaluate the home environment. It’s easier for me to remember our failures than the successes.

How do you envision GEM will develop in Singapore in the next 10 years?

There remains a lot of inertia both within ED and outside ED towards the progress of GEM. In the next 10 years, I hope the Government, as well as EDs ourselves, recognise that ED is an integral player in the continuum of care of the elderly patient. What we do (or don’t do) has tremendous impact on the healthcare system, in terms of over-admission of the mildly-sick elderly, or dangerously-discharging the frail senior. The epidemic of the elderly is already upon us. Failure to plan is as good as planning to fail.

(** Special thanks to volunteer writer Juliana Poh for doing this interview.)



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