Advance practice nurses meet needs of older patients and shift culture in Hamilton emergency departments

The challenge

Today, older adults account for about 17 percent of Canada’s population, but represent 42 percent of hospitalizations, 58 percent of hospital days and 60 percent of hospital-related expenditures.1,2 Meanwhile, the number of people aged 65 and older is expected to double over the next 20 years.

Older Canadians often arrive at hospitals with many inter-related chronic, acute health and social issues. Yet this population is often not well served by hospital-based models of care, providing an opportunity to rethink how we organize and deliver care for seniors.

Mount Sinai Hospital in Toronto spearheaded the Acute Care for Elders (ACE) Strategy and, as a result, has become one of Canada’s most widely recognized elder-friendly hospitals. The ACE model of care spans the emergency department, inpatient, outpatient and community care, delivering seamless care to older adults.

In its initial years at Mount Sinai, ACE has shown remarkable outcomes for patients, providers and health systems, including a 28 percent drop in total hospital lengths of stay, a 93 percent decline in the occurrence of pressure ulcers, 14 percent fewer readmissions within 30 days, and 11 percent fewer patients remaining in institutional care. Acute care cost savings from these improvements amounted to nearly $6.7 million for Mount Sinai in 2014.

CFHI, working with the Canadian Frailty Network and Sinai Health System, launched a 12-month quality improvement collaborative in 2016 to spread ACE. Seventeen Canadian teams and one international team participated, with Canadian teams each receiving up to $40,000 in funding, and all receiving coaching, educational materials and tools to support the adaptation of Mount Sinai’s elder-friendly practices and models of care to their local contexts. Resources included an online learning platform, educational webinars, an in-person workshop, and ongoing support from the ACE collaborative faculty and staff.

Most teams reported changes in culture because of the ACE collaborative, including changes in how data collection and measurement is perceived; greater compassion for the needs of elderly patients with dementia; and adjustments in daily practices. The shift in culture resulted in improved patient outcomes and more knowledgeable staff.

The solution

Eight hospital-based quality improvement teams in CFHI’s ACE collaborative implemented interventions focused on supporting older patients in the emergency department. These interventions included:

  • using evidence-based, high-risk screening tools such as Identification of Seniors at Risk (ISAR) and the interRAI emergency department (ED) screener for older adults presenting to the ED
  • employing the Geriatric Emergency Management (GEM) Nurse Model, where advanced practice nurses focus exclusively on assessing and addressing the needs of frail older patients
  • using the Geri-EM ED educational program, an e-learning website designed for ED physicians and nurses to provide optimal care to older patients

Hamilton Health Sciences (HHS) was one of two teams that worked to implement all three emergency department interventions. HHS has six hospital sites and six specialized healthcare facilities, and provides care to people throughout the life cycle. Roughly one third of people presenting to HHS EDs are 65 or older. At one site, the Juravinski Hospital and Cancer Centre, up to 40 percent of their patients are over the age of 65, and 25 percent of patients are over 75.

Juravinski Hospital has committed to providing elder-friendly care in their ED, and was the first HHS facility to embrace the ACE strategies. Participating in CFHI’s ACE collaborative enabled the hospital to “kick-start” this work.

Evidence-based screening tool

Juravinski introduced a standardized interRAI ED screener, also referred to as the Assessment Urgency Algorithm (AUA). The purpose of the tool is to identify seniors who have begun to experience or are at risk of functional impairments that could lead to hospitalization or loss of independence. The AUA is completed on all patients 65 years or older who arrive in the ED.

The questions asked in the AUA are designed to prompt additional, more in-depth questions about a patient’s health status and needs. Seniors are at risk of deconditioning quickly while in the ED, so HHS’s goal is to get supports in motion as quickly as possible.

GEM nurse mode

One key support is referral to Juravinski Hospital’s Geriatric Emergency Department (GEM) nurse. In September 2016, Juravinski hired a GEM nurse to facilitate uptake of elder-friendly interventions. The GEM nurse has a two-pronged role that includes capacity building among front-line staff and clinical care to patients.

In the capacity-building role, the GEM nurse ensures staff are aware in their assessments of potential risks for seniors. This includes ensuring staff complete the AUA screening tool. The nurse also provides education to front-line nurses about elder-friendly best practices and care. Through education and bedside teaching, the GEM nurse influences the approach to care, and shifts culture.

In the clinical care role, the GEM nurse provides direct clinical consultation to patients at high risk who are returning to the community. The nurse works alongside the ED interdisciplinary team, including other nurses, physicians, social workers, pharmacists, physiotherapists and home and community care workers to ensure patients are discharged safely. The role also ensures the patient and family know what to do in follow up to avoid repeat visits.

“Hiring the right person is key,” said Jennifer Kodis, Director of HHS’s Seniors, Emergency and Community Medicine Program. “The GEM nurse needs to be able to relate to the physicians and the nurses in the ED, and needs to be capable of shifting the culture. This means that a thorough, interdisciplinary hiring process is indispensable.”

Because of the challenges associated with introducing culture change, the GEM nurse role should be introduced gradually, said Kodis. A nurse with experience in geriatrics and a fast-paced setting is a must. “They have to know the setting and the patient population,” she said. “It has to be a team fit.”

Education program

In addition to front-line nurses receiving education from the GEM nurse, some physicians are receiving specialized training under the Geri-EM ED Educational Program. The education focuses on how treatment of the elderly differs from treatment of the younger population, as well as strategies to facilitate appropriate care in the ED.


HHS has hired a highly qualified, full-time GEM nurse five days a week during business hours and has plans to expand the role over seven days by hiring a second GEM nurse once the benefit has been established within the organization. In addition to successfully championing AUA compliance and staff education, the GEM nurse is liaising with long term care (LTC) homes. This has helped in the return of LTC patients who seek treatment in Juravinski Hospital’s ED. Juravinski’s goal is to return patients to their homes rather than admit them.

When Juravinski Hospital’s GEM nurse arrived in September 2016, staff compliance in filling out the interRAI AUA screening tool was about 45 percent. Today, by educating staff and using skillful diplomacy, the GEM nurse has increased compliance to 75 percent. Since the tool was introduced, referrals to home and community care have increased. All those scoring high on the AUA are automatically referred to the GEM nurse. If the patient is not admitted, they receive a call from home and community care agencies after discharge and are interviewed about their care needs.

On the education front, Juravinski Hospital delivered two types of education to staff. Small classes of one to four have been completed for 52 percent of staff. And 10-minute, one-on-one education at the bedside has been delivered to 95 percent of staff. The GEM nurse has delivered all education.

The hospital has begun to see a culture shift, despite initial resistance. Staff are beginning to refer patients to the GEM nurse, and will continue to receive direction about how to make appropriate referrals.

Since HHS adopted ACE initiatives in 2016, Juravinski Hospital has experience an 11 percent increase in visits from patients 65 and older compared to its baseline in 2014–2015. Despite this increase in volume, the hospital has not seen an increase in admissions overall.

Spread and sustainability

A significant relationship developed between Geriatric Medicine and Emergency Medicine at Juravinski because of the ACE collaborative. A pilot project in the fall of 2017 guaranteed that patients receive assessment by a geriatrician within 10 days of visiting the ED. The pilot was well received by patients, families and physicians, who felt better about sending patients home knowing they would have a comprehensive follow-up assessment.

Preliminary results have shown that 100 percent of patients have attended their follow-up appointment, and more than 80 percent are connected to another community service. While it is early days, the hope is that this strategy will reduce subsequent visits to hospital and improve the patient and family experience. HHS has initiated many other components of ACE. HHS is forming a corporate Seniors Advisory Council that will advise and support the spread and sustainability of all elder-friendly practices.

Care for the elderly is now part of Juravinski Hospital’s work plan; progress is reported quarterly to members of the ED Quality Council and to the hospital’s Executive Sponsor. HHS scrutinizes its ACE-related data and indicators regularly and has included ACE interventions in its annual work plan.

The GEM nurse position – a key to Juravinski Hospital’s success in implementing ACE practices in its ED – is permanent and now part of the hospital’s structure HHS’s GEM nurse is not merely a front-line worker. “She is part of our leadership team, which means her expertise and advice inform practice,” said Kodis. “She has a seat at the interdisciplinary leadership table.”

Advance practice nurses meet needs of older patients and shift culture in Hamilton emergency departments


1Canadian Institute for Health Information. Health Care in Canada 2011: A Focus on Seniors and Aging. Ottawa, Ontario:CIHI; 2011.

2CBC News online, May 7, 2017. Available at: