GEDI Nurses - front line geriatric care

Dr Elizabeth Marsden, Consultant Physician, Nambour Emergency Department (ED), saw a need for a new model to better support older people and residential aged care residents presenting to ED and the health professionals managing their care.
The journey began when Dr Marsden met with Amanda Glenwright from Sunshine Coast Medicare Local who had just concluded a pilot project into reducing non-urgent transfers of elders to the ED after hours. In mid-2014, with the help of a passionate team, Dr Marsden saw the launch of the CEDRiC (Care Coordination through Emergency Department, Residential Aged Care and Primary Health Collaboration) research project.
“I put an idea out there and that’s how this started,” shares Dr Marsden. “I wanted to implement this nursing model so I asked Clinical Nurse Consultant, Andrea Taylor, if it was feasible. She gave me an extensive critique and the idea developed from there. CEDRiC has come about through the efforts of an engaged and enthusiastic team,” she says.
CEDRiC has evolved through a partnership between Nambour General Hospital, The University of the Sunshine Coast (USC), Sundale Residential Aged Care Facility (RACF) and Central Queensland, Wide Bay, Sunshine Coast PHN, which replaced Sunshine Coast Medicare Local in 2015.

The early gains demonstrated in the CEDRiC pilot project provided a strong evidence base to support a successful grant application to the Department of Social Services, resulting in a two-year $1.15million research grant. This funding has provided specialist nursing staff in the ED and the RACF, project research staff and access to research specialists including health economists and statisticians.
Key Elements
The CEDRiC model establishes an effective process of communication and liaison with multiple personnel involved in the care of older patients. CEDRiC promotes the flow of information between a patient, ED, the RACF, their GP and family.
CEDRiC encompasses two streams of care;
1 HIPS
(Health Intervention Projects for Seniors) that includes provision of a Nurse Practitioner within the RACFs whose role it is to develop advanced care plans for residents, coordinate with GPs in care delivery and deliver training programs for staff.
2 GEDI
(Geriatric Emergency Department Innovation), pronounced Jedi, provides specialist clinical nurses on the ED floor for all patients over 70 years of age and from all RACFs. The GEDI nurses provide a dedicated, single point of contact within the ED for the patient’s RACF and other hospital departments and rapid, comprehensive geriatric assessment and management on presentation.
Kaye Coates, HIPS Nurse Practitioner based at Sundale RACF on the Sunshine Coast, says, “If a patient does need to be transferred to hospital from the nursing home, I prepare a summary of the findings for the GEDI nurses. This includes the aims of the hospital transfer highlighting that this person is presenting differently to their usual healthy baseline and this helps the hospital team determine the best management pathway.”
“If an elderly person with comorbidities presents at ED without this information, devising a management plan can be a long process for emergency staff and for the person concerned,” she says.
“CEDRiC Practitioner Nurses in nursing homes reviews complex health issues and advanced health directives or care plans while a patient is stable. This, along with providing support and liaison to the staff, GPs and the patients’ families will, I believe, lead to a reduction in unnecessary hospital admissions,” Kaye says.
“An example of how this process works would be the case of a 93 year old man, presenting with sudden onset shortness of breath and lots of frothy white sputum. His notes outlined a past history of heart failure that I determined was not the cause of his current situation which was acute pulmonary oedema secondary to aspiration pneumonia,” says Kaye.
“So the steps are;

• Assess the person


• Consult their advanced care plan or health directive


• Liaise with family, nurses and doctors


• Summarise the findings and use that information to determine if the patient will be managed in the residential setting or go to hospital.”

“If the patient is transferred to hospital, my assessment may help to guide the appropriate investigations and facilitate his safe discharge and palliation,” Kaye says.

The Gedi Order
On the role of the GEDI nurses, Dr Marsden says, “They assess an elderly patient when they arrive, streamline their stay and improve communications between hospital departments and the nursing home.”
“The GEDIs streamline patient flow and can refer directly to geriatrics and orthogeriatrics when appropriate, bypassing delays in ED. They promote communication between departments and facilitate discharge planning and education/training of health professionals,” she explains.
Staffing
“Feedback from recent qualitative data collected has suggested the ED staff would prefer 24 hour GEDI nurses, 7 days a week when funding allows. We feel this would be the gold standard, however as a bare minimum, we need to extend the GEDI team’s current hours coverage and have two GEDIs on the weekend,” Dr Marsden says.
Outcomes
It is anticipated that CEDRiC will reduce inappropriate transfer of RACF residents to ED, improve resident and family satisfaction with care, minimise hospital access block NP Kaye Coates from Sundale LTD with CN assisting resident of aged care. and provide a better level of care to older Australians while providing net reduction in or cost neutral Government expenditure.
Dr Marsden says, “The results of our research based on GEDI’s impact in the hospital, nursing home and community settings are still to be published but the preliminary numbers are extremely positive in terms of saving and return on investment.”
“And the cost savings figures do not take into account the patient benefits such as decreased mortality and morbidity from hospital acquired complications,” she says.
Central Queensland, Wide Bay, Sunshine Coast PHN Board Chair, Dr Peter Dobson states, “Our PHN has been involved with the CEDRiC project since its inception, and we are very proud of the team’s achievements to date. Our PHN contributed innovation funding to the pilot study period, and we were thrilled to hear that the project was reducing avoidable hospitalisations of the elders in our community. 2017 will be an exciting time as we will be able to share the evidence of this successful project.”
Professor Marianne Wallis, Chief Investigator, USC , shares her insights into the project. “Even from the preliminary model we are seeing a reduced length of ED stay and cost savings. So we are really optimistic about the outcomes from this project,” she says.
Next Step
Dr Marsden reflects on whether this model will be transferrable to other hospitals. “We will be implementing the GEDI model into SCUH, the Sunshine Coast University public hospital, when it opens,” she says.
“We are expanding the model to include a Geriatrician who will provide ED with access to specialist geriatric care. We will be bringing the Geriatrician to the front line.”