GEM Care is specially designed for seniors
Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Upstate Community Hospital's emergency department recently achieved gold standard accreditations for its care of older adults in the GEM Care unit. That's G E M for geriatric emergency medicine. Here to explain why GEM Care is so important is Dr. Jay Brenner. He's the medical director of GEM Care and also of the emergency department at Upstate Community Hospital. Welcome to "The Informed Patient," Dr. Brenner.
Jay Brenner, MD: Thank you, Amber.
Host Amber Smith: This may be the first listeners are hearing about GEM Care, so I'd like to start with a description of what this is.
Jay Brenner, MD: Absolutely. GEM Care is, as you said, the geriatric emergency medicine care unit that opened in 2013, 10 years ago, at the Upstate Community Hospital Emergency Department. And I've been a part of it since then. It is a dedicated eight-bed area within the emergency department, in a separate room, that has all of the physical plant features that one might want if you were a senior seeking emergency care. There's natural lighting from a large window. There's softer flooring that doesn't quite make the same loud noises that you hear throughout the rest of the hospital. There's digital clocks, for each of the beds, with noise reducing curtains between, each of the bays, so that you can see what time it is and not be disturbed by others around you.
Most importantly, though, this unit is staffed by nurses, physicians, other healthcare professionals who are trained to take care of patients who are 65 years and older, and pay more attention to some of the intricacies of taking care of patients in that age range.
Host Amber Smith: Is GEM Care open the same hours -- 24 hours -- like the emergency department is, or does it have certain days and times?
Jay Brenner, MD: Yes. As you just mentioned, the emergency department is open 24/7/365, and the geriatric emergency medicine care experience is provided during all 24 hours, seven days a week, 365 days a year. The actual space of the GEM Care unit is sometimes closed during slower hours. And so it depends on staffing.
That actual space may actually be not used during the wee hours of the morning. But on the most part, it is part of our functional space in the emergency department. And, again, the geriatric emergency medicine experience is open all the time.
Host Amber Smith: Who qualifies to be seen at GEM care? Is it anyone over age 65?
Jay Brenner, MD: Yes, quite simply, 65 and over is the age cutoff. If someone is in dire illness or injury where they're really at the extremes of cases that we see where their life may be under immediate threat, they may be seen in the regular part of the emergency department. But they will still be getting sensitive, senior-friendly care.
Host Amber Smith: Does a person need to call first or do they just arrive?
Jay Brenner, MD: We don't currently have a mechanism by which to expect patients who might call about coming into the emergency department unless they would be being transferred from another hospital or facility, such as an urgent care or doctor's office. Certainly we do take those sorts of calls. There is no need to call ahead. We are an emergency department and open, as I already mentioned, 24/7/365. We're ready for you.
Host Amber Smith: Does it cost more for patients if they go to GEM Care than it would to the regular emergency department?
Jay Brenner, MD: No, of course not. It's an emergency department bill. So in that sense, it may cost more of your copay than, for example, a doctor's office visit or an urgent care visit, but it is equivalent to the emergency department.
Host Amber Smith: Do you know what percent of emergency patients are over age 65?
Jay Brenner, MD: Right. So we're seeing about 15% to 20% of our patients arriving in that age category.
Host Amber Smith: And are there projections for how this may grow in the coming years or the need for more GEM Care?
Jay Brenner, MD: Oh, absolutely.There are some estimates that put it at 40% to 50% of emergency department visits by 2050.
But what we've seen personally in the last 10 years when we opened the GEM Care unit, we increased our geriatric patients who were visiting -- that is, our senior patients 65 and over -- at about a rate of 15%. So we saw an increase. Not a stark increase. And perhaps as awareness gets out there that we are now level 1 gold level certified geriatric emergency medicine -- which is quite a feat that we have achieved; you know, I think we're only in the 25th emergency department to have that designation in the country, and the first in Upstate, New York -- I think we may see an influx of even more patients seeking out that care. But it's something, certainly, that we'll pay attention to.
Host Amber Smith: Now we're talking about Upstate Community Hospital campus. What about downtown, at Upstate University Hospital? Do they have GEM Care as well?
Jay Brenner, MD: It's something that we are contemplating, extending the geriatric emergency medicine experience to our downtown hospital. In the meantime, there are some select components of it. For example, there is a effort to get patients who suffer a hip fracture to the operating room within 24 hours, as part of what's called the ortho co-care initiative, which is tapping into some of our knowledge and skills with our geriatric emergency medicine experience to try and get patients to the operating room within 24 hours. And that's happening both at community and downtown.
And then there are some other efforts, like trying to make sure that our medications are properly dosed, whether they be pain medications or sedative medications. And we're making sure that those are properly dosed at both departments.
Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Jay Brenner. He's the medical director of the GEM Care unit at Upstate's Community Hospital. So tell us about the Gold Standard accreditation. How did you earn that?
Jay Brenner, MD: Yeah. So, the American College Emergency Physicians, ACEP, which is the, the leading professional society of emergency medicine actually started accrediting geriatric emergency departments in 2018 and giving them either a gold, silver, bronze, or level 1, level 2, level 3 status.
And we looked into it at that time and started to prepare our data to share with them, and then Covid hit. So the Covid pandemic sort of waylaid us. We had to repurpose our GEM Care unit for Covid patients because it was a very good space to take care of patients in negative pressure, which prevented the germs from spreading.
And then we looked at it again when the founding medical director, Dr. Jamie Ciaccio of GEM Care phased out of clinical work into telemedicine work, and then eventually retired at the end of 2020, upon which I took over the unit and worked with our hospital quality services liaison, Amy Serzanin to really build up our data.
We submitted our application in July of 21. And after a couple of back and forth go arounds with ACEP had a visit from the reviewers, virtually, in February of 23. And they met as a board in April of this year and gave us the gold standard accreditation.
Host Amber Smith: Can you give us some examples of guidelines that ACEP established for geriatric EDs, or geriatric emergency departments?
Jay Brenner, MD: Yes, of course. So it requires not just staffing and education, but a series of policies and procedures that you can show you're adhering to. And so we, as a gold level, level 1 geriatric emergency department, we have to adhere to 20 or greater policies. And these policies include things like the medication dosing that I mentioned, but also avoiding Foley catheters unnecessarily. Also providing mobility, promotion and ambulatory assessments, so making sure that people can walk and get out of their stretchers, making sure they're getting food as soon as they can. making sure that they're getting case management to help them get into either home care arrangements for physical therapy and occupational therapy at home, or into skilled nursing facilities if they need it. And so all of these policies, including also fall risk prevention and dementia and delirium screening, all sort of fit into the whole geriatric emergency medicine experience.
And that's what ACEP has been really focused on making sure that we're providing soup-to-nuts senior friendly care from the time that you approach the triage nurse and the registration clerk to the time that you leave the emergency department, either to hopefully go home, with the services you need, or enter the hospital for inpatient care.
Host Amber Smith: I was going to ask, do most GEM Care patients get released to go home, or do they get admitted to the hospital?
Jay Brenner, MD: Yes. Most geriatric emergency medicine patients do go home. Our admission rate at the Community emergency department overall is about 20%. And for patients 65 and over it does go up to about 30%. But on the most part, patients will go home.
Host Amber Smith: So most of them, you're able to get stabilized and comfortable and well enough to return back home?
Jay Brenner, MD: Exactly, and that's the goal. We even tolerate even sometimes longer lengths of stay in the emergency department if we can provide the services to avoid an admission because we know that while there are some conditions that need to be managed inpatient, ideally the services can be brought to the patient at home.
As I think our audience may be aware, even when you need inpatient care, there is a special program that involves Upstate "Hospital at Home." And so there are some conditions that need hospital care, but after coordinating with our case management team, we are able to get patients -- for example, IV antibiotics and oxygen therapy -- things that they might need in the hospital, but actually at home with nursing care.
Host Amber Smith: So what are the most common medical issues you see in this patient population?
Jay Brenner, MD: Oh, that's a good question. It varies. Obviously, one of the things we saw earlier on in the Covid pandemic was COVID itself, as we are well aware in geriatric emergency medicine was more than anything a geriatric emergency. It really impacted the morbidity and mortality of our senior adults quite a bit. That being said, as we are crawling out of the pandemic, we are certainly seeing other infections, whether it be flu or bacterial infections, sepsis is a very common phenomenon in the geriatric population. And then patients will have various causes of delirium, like infection, but also other metabolic issues, cardiovascular disease, cerebral vascular disease, in other words, heart attack and stroke.
And a very common phenomenon, as well, is trauma. And usually that trauma comes in the flavor of falling. We see quite a bit of injuries from falls, and that's why we spend a lot of time trying to work on fall prevention. But then when falls happen, we try to not only identify the injuries that may have been suffered during the fall, but also the underlying reason why a patient may have fallen.
Host Amber Smith: Why do you enjoy working in geriatric medicine?
Jay Brenner, MD: Geriatrics is very exciting because these patients have actually very complex medical histories, often. And it can be a challenge that is both invigorating and rewarding to take care of. I'm doing this for my 81-year-old mother and my 74-year-old mother-in-law who access this care not infrequently. It gives, I think, our community great comfort to know that there's people sort of looking out for them as they age, hopefully gracefully.
Host Amber Smith: Do you have any advice for family members or friends who need to bring an older person to the hospital?
Jay Brenner, MD: Yeah. I'm so glad you asked this question, Amber, because when you're deciding if you should come to the emergency department or not, and perhaps you call your doctor or maybe a family member who is in healthcare and they advise you to go to the emergency department, we certainly want you to come, but don't forget to bring some of the important things that will help us take better care of you.
Medication lists that are updated is one of the top things. Any assistance devices that you might need. So we have walkers, so if you don't bring your walker, that's OK. We have walkers. But bring your hearing aids. We do have amplifiers if you forget them for some reason, you are leaving a hurry. you know, bring your visual aids, your glasses, right? Don't forget that in order to best take care of you, we need to be able to communicate with you. And whatever assist devices you need, that's really helpful.
And then for advocates, for family and friends that are bringing in a senior adult to seek emergency care, bring yourself. Visitors are welcome. We've, definitely made our visitor restrictions much more lenient as we're having much lower Covid rates. And so you need to come and advocate. We know that patients who have an advocate get sort of more attention for their needs, and we welcome you to do so.
One thing that I think is good to leave at home, and I shouldn't have to spell this out per se, but we've had this happen on occasion. You can't bring your pet, unless they are a registered service animal. And I realize that can be a little bit disconcerting because a lot of older adults really do find a lot of companionship and support by their pet, whether they're cat or dog or iguana. It's not something that we can accommodate for in this shared space.
The other thing is, as of this past Thursday, you no longer need to bring your mask. And honestly, you don't have to wear a mask. Masks are optional in our space. And we're of two minds with this. Certainly we want to reduce infection. But we're realizing that the mask was getting in the way of ideal communication. Certainly over the last three years of this pandemic, on many occasions I've worn a translucent mask so that patients could see my face through the mask protection and actually be able to perhaps lipread if they were relying upon lip reading. So you don't need to bring your mask. We welcome you, mask optional.
So just adding that in to the mix. And other than that, we have warm blankets. We have lots of comfort items, but I've seen patients on many occasions bring their own blanket, and that's okay. We're, not going to tell you to leave that at home. But certainly wear comfortable clothes because you are going to be asked to get into a patient gown like you would at any healthcare facility. And certainly there are people to assist you with that if you need assistance. And that's really about it. I mean, just bring yourself and any contact information that you might have for anyone that can help us best take care of you.
One other thing I should have mentioned. It's a bit of a sensitive topic, so I hesitate, but I think it's important that if you do have Medical Orders of Life-sustaining Treatment, or a MOLST form, that would be something that would be good to bring. It's good to know sort of what your wishes would be if there were any extreme measures that were needed to take care of you.
Host Amber Smith: Dr. Brenner, thank you so much for making time to tell us about GEM Care.
Jay Brenner, MD: Great. Thank you so much. And, hopefully you don't need our services, but if you do, you know where we are. And we're always glad to see you when you come.
Host Amber Smith: My guest has been Dr. Jay Brenner, medical director of the emergency department at Upstate Community Hospital and of the geriatric emergency medicine or GEM Care unit there. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at Upstate.edu/Informed. This is your host, Amber Smith, thanking you for listening.