Initiative aims to improve care for frail elderly patients

St. Joseph’s Health Centre is committed to recognizing the unique needs of patients and improving their experience in hospital, while providing high quality and safe care. One approach to enhancing care is through the First Three Days initiative, which focuses on frail elderly patients, enabling them to get home sooner by maintaining their independence and sometimes functioning even better than when they arrived in the emergency department (ED).

“Studies have shown that lying in bed for 24 hours is when you start to see muscle atrophy, and you become weaker,” explains Occupational Therapist Neelam Bal. “The first three days is a key period to get involved with patients and from day one we were getting the patients up and moving and starting our assessments.”

Through this initiative, we are able to identify frail elderly patients in the ED, as they are admitted to the Medicine Program, who can benefit from the expertise of Geriatrics, Nursing and Occupational Therapy staff through early, coordinated interprofessional assessment and treatment – that starts within the first 24 hours of their hospital stay.


Two years since the First Three Days pilot project started, this home-grown program has been successful in helping patients maintain their function so they don’t lose strength or their ability to perform normal activities; at the same time reducing the amount of time frail seniors stay in hospital.

“We are seeking to prevent the deterioration of general function that we see so commonly in hospitalized patients,” says Dr. David Tal, Chief of Geriatric Medicine. “A frail senior can lose muscle strength so quickly. Someone that was walking comfortably with a cane or walker, gets put on bed rest for two days, and then can’t stand. The goal is to treat the acute medical problem and not to lose ground in their ability to function, to spend those first three days already making the person feel better.”

Ultimately this initiative is looking to change the culture of care, as Dr. Tal explains. “We want to change people’s understanding so that the automatic approach to care is to get the person up and moving, doing normal activities such as sitting up in a chair, rather than the common care of bed rest.”


Senior care is an important area of focus for St. Joe’s as a community teaching hospital caring for the over half a million people living in Toronto’s West End. Thirty-four percent of residents living in neighborhoods surrounding St. Joe’s are over the age of 65 with nearly 14,000 patients over the age of 70 coming to the ED in the last fiscal year.

So why focus on frail elderly patients? Dr. Tal explains that these are individuals who are 70 years of age and older, have a degree of cognitive impairment, are taking multiple medications, live alone, and have had falls or are at risk for falls. All of these issues combined put them at higher risk for complications, making early intervention and assessment that much more critical for this group.

Patients 70 years and older also account for 35 per cent of overall ED admissions and tend to stay in hospital longer – nearly eight days, versus an average of three and a half days for patients younger than 70. They are also three times more likely to be re-admitted to hospital than others.

The First Three Days improved functional independence for patients by 50 per cent in the pilot project. “Our patients were also able to get home sooner. This is also about empowering our patients because we want them to feel that they can do for themselves and we’re here to support them in doing that,” says Bal.


Due to the success of the initiative over the last two years, additional funding has been provided to expand this approach to integrate more members of the interprofessional team, including physiotherapy, social work and rehabilitation assistant care. This additional support from the Toronto Central Local Health Integration Network will enable us to further evaluate the First Three Days program over the next six months, learning how to best incorporate this important aspect of care.

“The First Three Days is a great example of how interprofessional collaboration is really improving the patient experience,” says Shelley DeHay Turner, Interim Vice President of Clinical Programs. “We have reduced the length of stay by half a day and are aiming to reduce it even more to a full day. If we continue to demonstrate its success, we hope to explore opportunities to expand this for patients even more.”

“The First Three Days is all about people. It’s not about buying a new widget or device,” says Dr. Tal. “There can be innovation without technology and in this case it means changing the way people think about caring for the elderly and using the expertise of our professionals early in the course of a patient’s treatment.”