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GENI arose from the BC Ministry of Health, Nursing Directorate’s original care of the acutely ill older adult’s improvement project, the Acute Care Geriatric Nurse Network (ACGNN). Its inception 6 years ago was in response to a coroner’s report following the tragic death of a 77 year old within 14 days after undergoing an elective arthroplasty. The College of Registered Nurses of British Columbia (CRNBC) responded to this report and the family’s request to not have the same tragedy happen to other Seniors. Phyllis Hunt, CNS (gerontology) with CRNBC asked Marcia Carr (CNS – acute geriatrics, geropsychiatry) to work with the hospital and their staff. A few months later, the Chief Nurse Executive / Assistant Deputy Minister of Health, Anne Sutherland-Boal and the Director of the Nursing Directorate, Diane Clement, heard about the tragedy and the response. The rest is history, so to speak. The ACGNN CNS Collaborative grew in 6 years from 4 CNSs (Marcia Carr, Phyllis Hunt, Valerie Macdonald, Sandra Whytock) to its present group of 16 CNS from across BC whose clinical practice is embedded in the acutely ill older adult. Our vision has been to have all acutely ill older adults wherever they are receiving our health care services to be “welcomed” (rather than being regarded as burdens to our care and systems) by geriatric/geropsychiatric/geriatric rehab knowledgeable and skilled front-line health care professionals (especially nurses). The CNSs all volunteer their time over and above their usual jobs in order to make the vision a reality.
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The question asked by the system was, “Is there a better way to move older adults through and out of the ER?”
The driving force behind GENI was that the ER was over-flowing with older adults and acute care beds were at more than a premium. There was great anxiety and challenges facing the front-line ER nurses in trying to care for this special population. There were perceptions that many did not have to be in their ER as they did not really need this level of acute services. Ageism reigned supremely. The question asked by the system was, “Is there a better way to move older adults through and out of the ER?”. GENE pilot testing, one-day workshop at ENA in San Diego was a starting point. Additionally, within British Columbia, there were two examples of the Geriatric Emergency Nurse (GEN) who assessed, raised red flags and planned proactive care for selected older patients in the ER.
It was very apparent to the program developers of GENI that the ER
- has its own specialized culture, beliefs and values
- is fast-paced and high-intensity short-term care
- has specialized ER nurses whose practice centres on critical care knowledge and skills
- language is that of priority, based upon triaged chief complaints
- frequently sets the “tone” for ongoing patient care needs
- is the access point into hospital or discharge back to the community
- older adults appeared to be the population group that was preventing them from doing their ER work and were jamming up the flow in the ER.
- program and approach must be practical with a focus on making it easier to do the right thing and not the wrong thing.
GENI is a multi-modal program approach to improve the care of acutely ill older adults in emergency rooms. It was developed by a core group of health care professionals with the requisite knowledge, skills, abilities and experience in caring for acutely ill older adults in the ER. The implementation has been facilitated through the GENI Faculty which includes the core developers and additional discipline specific health care professionals to assure “expertise”. GENI quite literally started as a “locally home grown” program from Burnaby Hospital in British Columbia, that expanded to all of British Columbia, other provinces as well as Dublin, Ireland, because the Ministry of Health, Nursing Directorate grant funding support (2005-March 2008). Burnaby Hospital’s GEN demonstrated that through GENI and GEN, the length of stay in hospital decreased by 4 days for each patient that she worked with. At this point in time, GENI’s Ministry funding has ended. However, extra funds were provided this year to help with sustainability development.
The original GENI curriculum was pilot tested in 2005 and presented as a one-day workshop to 18 very experienced ER nurses. The overwhelming response included such comments as
- “ Oh my! How was I to know what I need to know when caring for Seniors when I did not even know what I did not know to even ask the questions to help?”
- “ I feel so guilty about what I said yesterday when an old folk from a nursing home was sent in and I said ,”this is an inappropriate transfer’”. I now understand how very ill she was and what I should have done.”
- “ All ER staff need to know this! It should have been included in our ER program”
- “ It needs to be at least two days! This is fundamental to our daily practice and too important not to happen!”
There are three key components to GENI:
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all ER nurses will have the “need-to-know” knowledge, skills and abilities about acutely ill older adults who they care for in the ER
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geriatric emergency nurse (GEN) will provide both front-line care and mentorship in care improvements within their ERs.
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Sustainability will be facilitated through the ACGNN CNS Collaborative to enable ongoing GENI and GEN networking.
GENI has evolved, morphed and will continue to be dynamically responsive to the learning and practice needs of the ER staff; especially nurses. Currently there is a GENI curriculum for the two-day workshop with accompanying power points and resources on CD. The “Geriatric Giants Quick Reference” binder which is a primary accompanying resource, was developed by the ACGNN CNS Collaborative in response to front-line staffs’ request to have “need-to-know” information on each geriatric giant syndrome and practice tips on what they can do. Since GENI is a network, each participant (e.g. ER clinical nurse educator, ER clinical resource nurse, Geriatric Emergency Nurse, ER managers and administrators, ER pharmacists, ER social workers, etc.) received all the materials to enable them as the “train-the-trainer” at their respective sites. The ACGNN CNSs continue to be their mentor and resource.
This lead to the development and the implementation of modalities that would raise front-line awareness that ER geriatric care is essential and foundational to their practices.
Engagement of the front-line due to time constraints and workloads was a challenge. This lead to the development and the implementation of modalities that would raise front-line awareness that ER geriatric care is essential and foundational to their practices. GENI 4-hour (ER geriatric care orientation package), GENI Telehealth by requested topics, GENI e-learning (30-45 minutes as an interactive module – available soon on acgnn.ca website), delirium, falls, medications, incontinence, chronic persistent pain, psychosis, wandering, medications for psychosis e-learning modules (in development and will be posted on website within next 6-9 months) and top specific video presentations of each GENI topic (30-60 minutes with speaker and accompanying power point).
Also, access to the University of British Columbia Care of Elders problem-based learning modules (18 geriatric giants’ modules that are much more in-depth and requiring 90 minutes for pre-reading and 90 minutes to complete a facilitated case study for an interdisciplinary group) is available through either ACGNN or GENI.
We have demonstrated that GENI plus GENs can increase patient flow and care of acutely ill older adults. The care of acutely ill older adults in the ER has been slowly but surely moving forward as a reality.
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