Dr Patrick Leung
Chairperson of GEM Subcommittee
Hong Kong College of Emergency Medicine
Hong Kong is one of the most densely populated area in the world. With global aging, 18.2% of the population in 2020 are elderly (age 65 or above). With an average annual growth rate of 2.98%, it is predicted that the elderly population will double in the next decade. Elders in Hong Kong enjoy longevity with a mean age of 83 years old for men and 88 years old for women. Yet coupled with multiple co-morbidities in elderly, many of them will eventually require hospital care and call for a heavy demand on the health care system.
Hospital Authority (HA) is the statutory public hospital services provider in Hong Kong and accounts for 90% of inpatient care. Tremendous demand puts significant stress to the system which results in congested in-patient wards and access block at the Emergency Department (ED). In the author’s hospital, some elders have to wait for 1 to 2 days in ED before getting admitted. The situation is very undesirable and may lead to adverse events.
In 2015, a project named “Frailty Unit” was set up in the Emergency Medicine Ward in author’s department. It is a six- bed unit and will provide Geriatric Emergency Medicine (GEM) service to frail elders who fulfill a preset inclusion criteria. The most common disease entities are falls, dizziness, sepsis and other geriatric syndrome.
The Frailty Unit adopts a multidisciplinary approach and performs comprehensive geriatric assessment for the patient. On the day of admission, the doctor will formulate a clinical management plan. ED nurse will perform comprehensive assessment with the patient assessment form. Our physiotherapist and occupational therapist will provide assessment on physical and mental status. They will advise appropriateness of ambulatory care at home or other institutions upon discharge. Community nurse and case manager will be engaged for discharge arrangement and follow up plan. Bed manager will be responsible for arrangement of rehabilitation bed if needed. The patient’s condition will be optimized and reviewed at the frailty ward rounds in consecutive days. Those optimised will be discharged home while those needed further management will be transferred to convalescent hospital for rehabilitation. Two thirds of patients can be directly discharged back to their home within 3 days.
In order to further improve GEM service to the elders, regular meetings are held among the stakeholders of the team, which include ED physicians, ED nurses, geriatric nurses, geriatricians, community nurses, pharmacists, occupational therapists and physiotherapists. Logistics are reviewed and audits are regularly conducted (Picture 1). Moreover, in-house training workshops are organised regularly by our department to equip our colleagues with the knowledge and skill in taking care of elderly patients.
At the corporate level, a program called “Enhanced geriatric support at ED” is launched in phases by the HA since 2020. This is a joint program between ED team and Geriatrics team with the aim to provide additional support and alternatives to the elderly other than hospital admission. The ED Team employs a simple screening tool (Clinical Frailty Scale >4) and other inclusion criteria to identify those vulnerable elders. They work closely with the geriatric team who will conduct in depth assessment on the functional, cognitive and social need of the identified elders. The two teams discuss and decide the most appropriate care plan. Options include discharge back home with enhanced social support, refer to Geriatric Day Hospital for short course training or an early appointment at geriatric clinic if necessary. This enhanced program has started in the author’s department for 1 month. It is running smoothly so far. The author is looking forward to sharing the progress in near future.