Rehab destination…from the ED?

Going home or getting admitted. Is there another alternative for our older adults in the emergency department? Of course, and rehab is one of them.

I am in the middle of a rotation in a geriatric rehab facility. I knew it was a place to get better and stronger before going home but I was not exactly sure of their mandate and their success rate. Let’s review it.

Functional decline is often precipitated from an acute medical illness and hospitalisation hazards. If you had a frail state and multiple co-morbidities, it is the perfect cocktail for disability.

Geriatric rehabilitation is “a branch of geriatric medicine concerned with limiting the extent of disability, preventing functional and social decline and delaying or preventing loss of independence and institutionalization…” (AGS education guidelines 2002).

Their favorites clients are frail and medical complex older adults. Isn’t that perfect?!

A study from Bachmann et al in the BMC in 2010 showed that a rehab stay clinically and significantly improves function, decreases nursing home admissions and decrease mortality.

But what exactly are they doing to get these results? What is their secret?

INTERDISCIPLINARY TEAM!

  • A geriatrician is present as a consultant and provides follow up from the acute care setting on the geriatric syndromes.
  • A nurse practioner links each team assessment.
  • Physiotherapist and occupational therapist are in charge of the functional and cognitive assessment and rehab sessions, usually every day depending on the intensity of rehab.
  • A social worker deals with disposition issue
  • A pharmacist review all medications
  • Nurses staff provide care and additional information on cognition and function
  • A hospitalist is in charge of the complex medical care plan

There is a variety of rehab type depending on the disease. For example, there is a TBI rehab, a stroke rehab, a musculo-squeletic rehab, a geri-psych unit (to stabilize behavior issues) and a general rehab.

They also offers outpatient follow up clinics, falls clinics and general geriatric clinics.

The ultimate goal: optimization of function and quality of life.

But in order to get to these results, it is important to identify a realistic rehab goal and a desirable outcome. Because, even if the patient could have a benefice from rehab, there are a few situations that could affect the outcomes. For example, a patient may not be able to participate because of cognitive impairment. A patient may already be in a longterm care facility. A patient may have a complexe medical history with a very limited life prognosis. Therefore, in these situations, outcomes from rehab may not be achievable or realistic.

Here is an example of a case from the ED that could be a could fit for rehab. An independent 84 years old male from home without support fell from his height because of a new hypertension medication recently introduced. He was suffering from a non displaced non surgical pelvic fracture with a “weight bearing as tolerated” prescription. He can do a few steps but clearly not take care of himself while the fracture is healing. The gem nurse was in charge, PT and OT saw him and found that he was perfectly suitable for rehab with a goal of returning home with a walker possibly with extra support. An admission was avoided and its hazard!

There is more other options than home or admission for complex older adults. Find what is around in your community and once again, have an INTERDISCIPLINARY team in your ED. This is THE key!!!

 

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