Mark Er and David Madzinga
Hornsby Ku-ring-gai Hospital (HKH) is a major metropolitan hospital located on the northern suburbs of Sydney, NSW, Australia. Our Emergency Department sees roughly 43,000 presentations a year, of which about a quarter of these presentations are in patients aged 65 and over. HKH has over forty residential aged care facilities (RACFs) within its catchment area.
In 2005, HKH developed a service model – the Geriatric Rapid Acute Care Evaluation (GRACE) Team. This initially started as an ED-led model of care, with a Clinical Nurse Consultant providing telephone and in-person support to RACFs, with one of the primary goals being hospital avoidance for geriatric patients. For example, GRACE would provide services like IDC changes and wound care and dressing changes. This service model proved to be very successful and has since been adopted by other Health Districts within NSW.
GRACE has evolved over the years, and Dr Nadia Bowman, who is the current Geriatric Emergency Medicine (GEM) supervisor, was the first ACEM trainee to undertake this GEM special skills term at HKH in 2016. GRACE is currently led by Dr Radhesh Baskaran (Consultant Geriatrician), with the team comprising ourselves (Mark and David), as GEM Registrars, and also Clinical Nurse Consultants. We currently job share the GEM Registrar role, and between the both of us, our time is divided between working with GRACE and also working in the ED.
Days with GRACE are always interesting ones. The day starts with a team huddle and reviewing cases for the day. We receive direct referrals from RACFs and GPs, but also referrals on patients who may have recently been seen and discharged from the ED or even inpatients who have been recently discharged. We discuss and triage referrals and schedule visits to RACFs for the day. Reasons for referral range from non-specific complaints such as lethargy or confusion, to potentially more serious complaints like chest pain. In such scenarios, it may be that the patient and family are declining hospital transfer, which may be due to baseline frailty and expressed wishes for hospital avoidance.
We then drive out to the RACFs to perform our assessment. In the COVID-era, many facilities require us to undergo a COVID-19 Rapid Antigen Test at the doors prior to being allowed entry. Being Emergency Medicine trainees, this opportunity to assess and manage patients in the community, without the same resources that we are accustomed to having, has certainly allowed us to further hone our clinical acumen. For example, we might have to assess a patient with chest pain, without an ECG and troponin result almost immediately at hand, which are things we often take for granted in the ED. We carry equipment packs with us, and if clinically indicated, may insert an IVC and collect blood samples for pathology, which we would then take back to the hospital laboratory to be run. We can also initiate a wide range of IV therapy including antibiotics and diuretics. A key role we play is also in taking the important opportunity to have delicate conversations with patients and their families about what their values are and what our goals of care should be. Depending on the clinical context, we sometimes recommend transfer to ED for further assessment, but more often than not, our aim is hospital avoidance, and we will initiate treatment, and return to review the patient if necessary to monitor their clinical progress.
The team also monitors the online NSW ambulance portal, where all calls are logged, to try and identify appropriate patients that we may be able to review in the community, and hence avoiding a hospital transfer if able. With each presentation to ED being an exposure risk for vulnerable patients, especially in the age of COVID-19, the role of GRACE is ever more important in trying to keep patients at home if possible.
The rest of our time as GEM Registrars is spent working in the ED, where we have clinical and non-clinical roles. Our clinical roles include the supervision of junior doctors in their assessment and management of geriatric patients. We also work closely with the Aged Care Services Emergency Team (ASET), which plays an important role in assessing the supports that geriatric patients have in the community, and taking steps to provide more support for our patients if required.
We are also involved in a variety of non-clinical and quality improvement areas. For example, we have held a GEM workshop for ED trainees, and are also involved in individual projects. Mark is currently collaborating with the Emergency Care Institute (ECI) NSW on updating their Geriatric Clinical Guidelines. David is co-authoring some chapters of a proposed geriatric emergency manual.
We have been very fortunate in our role as GEM Registrars to be able to develop both clinical and non-clinical skills that help us develop as Emergency Physicians, while making a meaningful impact on care provided to geriatric patients. GEM registrars work under the supervision of a Director of Geriatric Emergency Medicine, who is currently Dr Nadia Bowman.
ACEM Trainees who are interested in undertaking a Geriatric EM placement at HKH are welcome to contact Dr Nadia Bowman – [email protected]