Are you aware that the Institute of Medicine estimates that health care systems require, on average, 17 years for 14 percent of high-quality, practice-changing research to reach the bedside? Multiple leaks in the “knowledge translation pipeline” contribute to this knowledge decay at the patient–provider interface, led by awareness and acceptance. Implementation scientists understand that traditional educational efforts and published manuscripts alone are insufficient to drive practice change. Alternative outside-the-box thinking is needed.
The ACEP Geriatric Section, in conjunction with the American Geriatrics Society and the Society for Academic Emergency Medicine Academy for Geriatric Emergency Medicine, and with funding from the John A. Hartford Foundation, recently developed the Geriatric Emergency Department (GED) Boot Camp to assist hospital systems interested in “geriatricizing” their community EDs. The core components of this boot camp are based upon the ACEP Board of Director–approved GED Guidelines.
First, contemporary geriatric care mandates an interdisciplinary approach, especially in the ED. By necessity, most off-site medical conferences like the ACEP Scientific Assembly are attended by only a fraction of each institution’s health care team, because somebody has to staff the ED. In addition, cost constraints increasingly affect attendees’ abilities to travel to conferences. More importantly, these conferences are focused toward one specialty and one set of health care providers: nurses or physician extenders or physicians. In contrast, the two-day GED Boot Camp brings the curriculum and expertise to the individual hospital system so that local nurses, technicians, physical therapists, case managers, hospital administrators, insurers, community organizations, patient advocacy groups, and physicians from multiple specialties have the opportunity to attend and participate without incurring travel expenses.
Second, the needs of each hospital to “geriatricize” care efficiently and effectively must be identified by their leadership. A one-size-fits-all educational product is unlikely to be of uniform utility for every hospital. Therefore, the GED Boot Camp includes a pre-event needs assessment survey. Each GED Boot Camp site self-identifies their programmatic priorities, curricular needs, and short-term objectives based upon this survey. Each GED Boot Camp program is therefore customized and developed to meet the needs and objectives of the participating hospital site.
Third, because traditional didactic education is usually insufficient to change practice or advance the standard of care, each site identifies at least one quality improvement (QI) project to adapt the GED Guidelines for their institution. The specific QI project for each site requires engagement of local opinion leaders and hospital leadership, access to meaningful before and after patient- or system-level metrics, and a process to measure adaptability of individual GED Guidelines. The QI projects identified by each site are monitored by GED Boot Camp faculty for one-year after the event to access outcomes.
Fourth, a two-day workshop is unlikely to be attended by all key personnel from a site, even when the workshop is at the site. Knowledge acquisition often requires repeated exposures to concepts and data. Furthermore, some components of the GED Guidelines are more readily operationalized if they can be linked to electronic medical records or technological resources to ease the burden of screening. Therefore, the GED Boot Camp initiative is also building a website to archive key concepts, instruments, and calculators, while providing a portal for multiple-site Boot Camp sites and attendees to connect, exchange geriatric QI ideas and resources, view updates in the medical literature, and participate in mentorship.
With support from Aurora Health Systems and University Pittsburgh Medical Centers Health Systems, the first two GED Boot Camps occurred in Milwaukee and Pittsburgh in December 2014 and January 2015, respectively. The Aurora Boot Camp was attended by 40 participants from three eastern Wisconsin hospitals ranging from ED physicians, physician extenders, and nurses to case management workers, geriatricians, hospitalists, and home health and hospital administration. All three Aurora hospitals selected QI projects focused on ED triage nurse risk stratification of older adults and referral to outpatient resources available through home health programs, the Aging Disability Resource Center, and other community resources. The Pittsburgh Boot Camp was attended by 35 wide-ranging participants from three western Pennsylvania hospitals. Their hospitals selected a structured triage nurse-emergency physician delirium screening intervention QI project.
The GED Boot Camp offers the opportunity to gather information and data gleaned from the practical experience of implementing the guidelines, identifying barriers to success as well as potential unintended consequences for those trying to achieve compliance with the guidelines. The attributes, limitations, and adaptable elements of the GED Boot Camp will be explored in coming months, but the organizers believe that with appropriate funding and administrative support, this idea can reduce some of the research-to-bedside knowledge translation delays that occur between publication of guidelines and real world health care delivery. The concept of content-expert guided education tied to a measurable implementation project to improve geriatric care one hospital system at a time has captured the attention of the John A Hartford Foundation. Preliminary discussions are underway to determine if this foundation, in collaboration with others, may facilitate the wider and more efficient dissemination of excellence in geriatric ED care nationwide.
Dr. Carpenter is associate professor of emergency medicine and director of evidence based medicine at Washington University School of Medicine in St. Louis. Dr. Biese is associate professor of emergency medicine and internal medicine, division of geriatrics at the University of North Carolina at Chapel Hill School of Medicine. Dr. Hogan is assistant professor, sections of emergency medicine and geriatric and palliative medicine, at the University of Chicago. Dr. Hwang is associate professor of emergency medicine and geriatrics and palliative medicine at Mount Sinai Hospital in New York City. Dr. Malone is the American Geriatrics Society’s liaison to ACEP. Dr. Melady an emergency physician at the Schwartz-Reisman Emergency Centre at Mount Sinai Hospital in Toronto, Canada.
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