Geriatric Emergency Medicine (GEM)

This provides a unique service allowing frail older patients presenting to the ED to receive integrated and multidisciplinary care in an appropriate environment from the moment they arrive. Care is initiated within the main department by medical and nursing staff with a specific interest in Geriatric Emergency Medicine, which can then be continued by another team working within the Emergency Frailty Unit (EFU).

There are a variety of training opportunities and we are always developing new educational resources for staff wishing to further their knowledge in caring for frail patients in urgent and emergency care, and the department has a strong record of research publications and quality improvement within the field of geriatric emergency medicine. 

Interested in...

• Developing your skills in geriatric emergency medicine? Click here to register for our training course.

• Interested in making your own department more frail friendly? Click here to view of geriatric emergency medicine for managers page.

• Want to know more about Geriatric Emergency Medicine in a national and international context? Visit our news and general resources page to see what is going on in the rest of the world.

A Frail-Friendly Front Door

We have been working on developing services for older people in the Emergency Department (ED) for many years, building towards establishing the UK’s first ‘frailty friendly’ Emergency Department, that came on line in March 2017.

We are currently working on developing frailty identification systems that are quick and simple to use in the ED setting, with a view to directing clinical care. We try to ensure that all older people with frailty who are identified in the ED undergo Comprehensive Geriatric Assessment. This is achieved through emergency physicians working with a team of frailty nurses (Locally known as ‘Primary Care Coordinators’), therapists and geriatricians – either in the ED or in our Emergency Frailty Unit, collocated in the ED.

We are well aware that ‘successful’; urgent care requires a whole systems approach, exemplified by our Leicester, Leicestershire & Rutland collaborative system leadership (‘Interface Geriatrics’), which lead to the development of national, inter-collegiate, inter-disciplinary guidance for the care of older people with urgent care needs (Silver Book).

Our learning has influenced the wider NHS, e.g. site visits from more than 30 UK hospitals, international visits (New Zealand, Ireland), visitors from the Royal College of Physicians’ Future Hospitals Commission and the Royal College of Nursing. Our work has been disseminated in a range of national websites, e.g. Future Hospital Commission and ‘Fab NHS stuff’, was shortlisted for the HSJ efficiency awards 2012, highly commended by NHS Innovations in 2012 and won the UHL ‘caring at its best’ award in 2013. Our work was cited by the Health Select Committee in 2013.

The hospital is in the process of building a new emergency department, to include our Acute Frailty Unit (AFU) as well as the Emergency Frailty Unit (EFU). The new building plans underwent extensive consultation with clinical leaders in the field of geriatric and emergency medicine and nursing to ensure they were appropriately designed to provide care for frail older patients. Click here to view the new floor-plans of our specially designed frail friendly Emergency Department.

The Emergency Frailty Unit (EFU):

The EFU is an 8 bedded unit within the Emergency Department where frail older patients can be assessed and managed for up to 24 hours. The aim of the EFU is to provide Comprehensive Geriatric Assessment in an emergency care setting to older people with frailty.

The service focuses on those patients likely to be able to return home the same day or the next day (ambulatory care), through care provided in the EFU but also through in-reach to the rest of the ED. Patients likely to need a longer admission are directed to the AFU. Below is a typical experience in the EFU:

Defining and Identifying Frailty in the ED

Frailty is a distinctive late-life health state in which apparently minor stressor events are associated with adverse health outcomes. The two established international models are the frailty phenotype [2] and the cumulative deficit model [3], both of which have been validated in large population studies. The models identify people at increased risk of a range of adverse outcomes including dependency, institutionalisation and premature death.

However, there is limited evidence for the discriminant ability of frailty scales in the urgent care context: although most scales perform better than chance in predicting a range of poor outcomes, none of them performed adequately, and most perform either poorly or very poorly [2, 4, 14].

When defining a population for intervention in clinical practice, acceptability and ease of use are important considerations as well as discriminant ability [15]. Until more accurate tools become available, it is recommended that simple, clinically acceptable criteria are used to identify a large proportion of frail older people (sensitivity); the risks are that some older people without frailty will be included (specificity – usually inversely related to sensitivity).

A frailty service will usually be able to manage non-frail older people, or at least identify them and re-direct if appropriate (whilst the converse does not always apply). Studies are underway that will help develop automated frailty identification systems with higher discriminant properties; these should be available in 2017.

An example for frailty identification criteria can include the following:

• Age 65+ AND presenting with one or more frailty syndromes (confusion, care home residents, Parkinson’s disease, presenting with fragility fractures and/or falls AND ≥3 falls in the last three months) OR people aged 85+

AND/OR

• Moderate or severe frailty (grade 6-9) using the Canadian Frailty Scale (Appendix 1)

The Canadian Frailty Scale is derived from the Rockwood frailty index and has been tested in a number of studies and found to be a moderately accurate predictor of adverse outcomes for older people in the acute care context [5, 22, 23].

Education and Training

We established the first UK training programme in GEM, which involved emergency physicians (trainees and consultants) taking time out to spend up to a year training in geriatric medicine. During this period, the emergency physicians learn the core principles of geriatric medicine through working in geriatric ward teams and in the various subspecialty services (psychogeriatrics, falls/syncope, Parkinson’s, stroke and so on).

GEM fellows also spend time working across the frailty pathway, including not only urgent care, but community services and a wide range of other learning opportunities. To date we have worked with seven GEM fellows, two of whom have gone onto be appointed locally as consultants in GEM.

Our GEM team are well-regarded and have delivered extensive local, national & international presentations and GEM. Members of our team are involved in developing GEM at the European level and are founding members of the European Union GEM Special Interest Group, which is a collaboration between the European Union Geriatric Medicine Society and the European Union Society of Emergency Medicine. An early output of this collaboration is the development of the European Union GEM curriculum.

Training opportunities

Registrars:

Leicester offers 1 year tailored clinical and quality improvement fellowships in Geriatric Emergency Medicine for registrars in Emergency Medicine or Geriatric Medicine wishing to develop their skills at managing frail patients in the ED. Trainees who have undertaken these fellowships have progressed to consultant posts with a specialty interest in GEM.

Consultants:

Interested in working in Leicester as a consultant with an interest in GEM? This video produced by Health Education East Midlands (HEEM) showcases some of the fantastic opportunities available to trainees to live, learn and train in the East Midlands.

Previous fellowship testimonials:

Dr Sarah Vince, ED Consultant at Northampton General Hospital:

"I was the first trainee through the UHL fellowship in Geriatric Emergency Medicine and have nothing but praise for my time there. I was trained by an enthusiastic and knowledgeable team who welcomed the new post.

I enjoyed hospital placements learning the basics of the 'Geriatric Giants' on a base ward and on the Medical Admissions Unit. I also spent time in two community hospitals and the local hospice which were very valuable experiences. I attended numerous out-patient clinics including falls, dementia, vertigo and incontinence.

The two most inspiring experiences of my year, which I still talk about when I deliver teaching, were observing one of the consultants as they took part in Advanced Care Planning at a local nursing home and taking part in the Falls Prevention Program.

There were plenty of opportunities to take part in and lead on quality improvement projects and research. I designed pocket reference cards for junior doctors in geriatric medicine and helped design admission documentation for frail elderly people on the Medical Admissions Unit. I also presented at a national conference.

The skills I learnt in my fellowship year helped me secure a consultant post in my first choice hospital and I have gone on to develop award winning services based on the foundations built during my GEM Fellowship in Leicester."

Editorials, Blogs, Websites and More...

International Collaboration in GEM

EU Task Force on GEM (ETGEM) – The EUSEM Geriatric Section and the European Geriatric Medicine Society (EUGMS) have established a joint task force with the following objectives: To develop a European Curriculum on GEM; To propose a draft for a European Course on GEM; To develop European Research on GEM; To organise scientific joint sessions at EuSEM and EUGMS congresses; To submit two papers on the GEM curriculum and GEM research in the European Journal of Emergency Medicine. Production of a European Text Book on GEM; To set a strategy for getting finances to support Task Force activities; To set quality indicators and guidelines.

EU Society Emergency Medicine (EuSGEM) – The mission of this new EUSEM section is to develop GEM with collaboration between emergency physicians and geriatricians involved in two different societies, European Society for Emergency Medicine (EuSEM) and European Union of Geriatric Emergency Medicine

European Union Geriatric Medicine Society’s Special Interest Group on Emergency Geriatric Medicine (EuGMS SIG EGM) – The mission of this new SIG is to develop GEM with collaboration between emergency physicians and geriatricians involved in two different societies, European Society for Emergency Medicine (EuSEM) and European Union of Geriatric Emergency Medicine.

Research

In Leicester, our ambition is to improve outcomes for frail older people by embedding evidence based medicine into clinical practice (‘campus to clinic’ translational research), with a focus on emergency and acute care.

Much of our work is health services research, looking at how to deliver more efficient and more effective services for older people with frailty in the ED and the Acute Medical Units. Some of our key projects are listed here:

• £1,038,561 – NIHR HSDR, (2014-17); acute hospital care for frail older people.

• £10,000 – British Geriatrics Society, (2015-16); the use and abuse of urine testing in older people.

• £386,751 – NIHR SDO, (2012-14); establishing and implementing best practice to reduce unplanned admissions in those aged 85+ through system change.

• £2,200,000 – NIHR programme grant, (2008-13); medical crises in older people.

Updated: 19th June 2018