There are many reasons for emergency clinicians to avoid hospitalizing patients when appropriate alternatives are available. Expenses can be reduced drastically, but so can the incidence of hospital-associated risks like central line-associated bloodstream infections (CLABSI) and methicillin-resistant Staphylococcus aureus (MRSA) infections. Furthermore, research shows older adults face even greater risks when they are hospitalized, including a heightened potential for falls, ulcers, adverse drug reactions, and functional as well as cognitive declines.

Consequently, while hospitalization is required in many cases involving older adults who present to the ED with acute care needs, interventions that can help facilitate the discharge of appropriate patients to the home setting may offer considerable value in both clinical and financial terms. In fact, new research involving three medical centers suggests that older patients seen by transitional care nurses with geriatric training are less likely to be admitted than similar patients who do not receive these specialized evaluations.1 Investigators studied the care of more than 57,000 patients over the age of 65 years who presented to EDs at the participating sites between 2013 and 2015. Roughly 10% of these patients were seen by transitional care nurses, and these patients were, on average, 10% less likely to be admitted when compared with similar patients who were not evaluated by a transitional care nurse.

In other findings, researchers reported that at two of the three participating sites, inpatient admission rates remained lower during the 30 days following the ED visit for the patients who were seen by transitional care nurses in the ED and discharged to the home setting compared to similar patients who were not seen by transitional care nurses.

Consider Potential for Discharge

While further investigation is warranted to assess ED revisit rates among the patients seen by transitional care nurses, investigators noted that the study offers evidence that there is value in providing ED-based, geriatrics-focused care to older patients deemed at risk by clinicians. Further, the approach used by the participating medical centers in this study offers a roadmap for other EDs that consistently see a significant number of older adults.

Because of demographic changes in recent years, EDs are seeing a growing number of patients older than 65 years of age. The Emergency Care Research Institute notes that this population now accounts for 25% of all ED visits. In response to this trend, many hospitals have developed ED-based geriatrics initiatives or changes.

For instance, the three participating centers in this study (Mount Sinai Health System in New York, St. Joseph’s Regional Medical Center in Paterson, NJ, and Northwestern Memorial Hospital in Chicago) follow the Geriatric Emergency Department Innovations in Care through Workforce, Informatics, and Structural Enhancements (GEDI WISE) model, an approach developed to address the unique healthcare challenges of this growing population of older adults.

A key part of the GEDI WISE model is the transitional care nurse, explains Ula Hwang, MD, MPH, the lead author of the study and an associate professor of emergency medicine, geriatrics, and palliative care at the Icahn School of Medicine at Mount Sinai.

“This is a nurse who is based in the ED and is focused on facilitating assessments and identifying patients who can benefit from care coordination that will [ease] their transition of care out of the ED, primarily with the goal of having them discharged ... hopefully back to home,” she explains.

Transitional care nurses don’t necessarily evaluate all older patients who present to the ED. Rather, these nurses focus on patients who potentially can be discharged, Hwang notes.

For instance, a patient who arrives at the ED in cardiac arrest and is intubated is going to be admitted, so a transitional care nurse will not see this patient. However, a patient who has been discharged from the hospital recently and has some ongoing chronic health concerns may benefit from seeing the transitional care nurse to determine what added steps or interventions can help this patient avoid a readmission. Hwang says that a typical case might involve a patient who presents to the ED complaining of dizziness.

“We know in the background that this patient recently had his diuretic medication changed, and perhaps the dosing is too high,” she says. “The patient is in the ED with a nonspecific complaint of dizziness, he is not acutely ill, and he is not someone who needs to be resuscitated.”

The transitional care nurse likely will assess the patient’s functional status and cognitive function, and then ask about the patient’s medications, Hwang observes.

“The nurse will then have a geriatric pharmacist review the patient’s medications,” she says. The pharmacist will identify that the patient’s diuretic was hiked recently, and adjust the dosage.

“The transitional care nurse might now be able to reach out to the primary care provider [PCP] and explain that the patient is in the ED for dizziness and that [the pharmacist] is going to modify the patient’s dosage so that his blood pressure does not drop dramatically, causing the dizziness,” Hwang explains.

The nurse can arrange a follow-up appointment for the patient with his or her PCP so that there is a clear handoff and the patient’s blood pressure and symptoms of dizziness are monitored appropriately.

“The nurse can also make sure that the medication is filled with the appropriate dosing before the patient is discharged,” Hwang says.

The nurse will make a follow-up phone call to the patient later to make sure he or she is feeling better and answer any questions the patient may ask, Hwang adds. “Knowing how to facilitate all of this is an example of what a transitional care nurse could do,” she says. “Maybe it is going to take a little bit longer in the ED because you are going to make all these calls to the [PCP] and coordinate the medication management, but you have also just saved the hospital money because you have avoided a hospital admission.”

While the goal is to avoid an unnecessary hospital admission, the transitional care nurse also focuses on taking a more holistic view of the patient. “It’s looking at their function [in terms of their ability to walk], their psychosocial elements, and what is going on with their social supports at home,” Hwang says. “Understanding the bigger picture is what makes the geriatric transitional care nurse different from someone who might be looking at the transitions of care for someone with sickle cell anemia or younger patients who are homeless and have other types of social support needs that are very different from the older population.”

Typically, a transitional care nurse will assess patients for cognitive function, delirium, agitation, functional status, fall risk, and any signs of caregiver strain. The results of these evaluations will guide what care coordination or support services may be needed so that the patient can be discharged safely. However, Hwang notes the three centers involved in the study have developed their own approaches for identifying patients who require a transitional care nurse and for implementing the overall GEDI WISE model.

For instance, Mount Sinai and St. Joseph’s have created distinct geriatric EDs, and Northwestern Memorial Hospital has elected to offer the GEDI WISE program components as part of the main ED.

“We don’t have a specific space that is dedicated only to older adults, although we do have some rooms that are designed with older adults in mind,” explains Scott Dresden, MD, MS, FACEP, a co-author of the study and director of geriatric emergency department innovations in the department of emergency medicine at Northwestern Memorial.

Dresden notes the senior-friendly rooms feature doors instead of drapes, nonskid floors, and (generally) windows. “We try to get our older patients placed in those rooms as much as possible, but we use them for other patients as well, especially cancer patients,” he says.

However, aside from this handful of rooms, the ED at Northwestern Memorial has focused primarily on providing senior-focused care through the transitional care nurses (referred to as GEDI nurses here) and a team consisting of an ED-based pharmacist, physical therapist, and social worker who are on hand to work with the GEDI nurses. “The GEDI nurses will go to the patients wherever they happen to be in the ED,” Dresden notes. “They don’t have to be in a designated space.”

Establish a Baseline

What triggers the involvement of a GEDI nurse in a patient’s care at Northwestern Memorial? Generally, an emergency physician or nurse will request a GEDI nurse when they raise concerns about an older patient and think that added evaluation would be helpful in optimizing the patient’s care and eventual disposition. Dresden notes that a typical example might involve a patient who has multiple medical problems, takes several medications, and appears confused.

“The GEDI nurse will do a thorough evaluation, looking for delirium, dementia, fall risk, polypharmacy, and those sorts of things,” he says. “They will do an overall, comprehensive evaluation and then work on trying to do the care coordination for whatever the patient needs, whether that involves the pharmacist in the ED, the physical therapist, or our social worker in coordination with primary care.” In the early days of the GEDI WISE program, the ED used an instrument called the Identification of Seniors at Risk (ISAR) score to assess all older patients at triage to determine whether evaluation by a GEDI WISE nurse was warranted.

“That is still the recommendation of the Geriatric ED Guidelines that were published and endorsed by ACEP [American College of Emergency Physicians], ENA [Emergency Nurses Association], and the American Geriatrics Society, but we found that this screening was not very specific,” Dresden says. “We had a lot of patients who would screen positive, but the nurses kept saying that [the screening] wasn’t all that helpful.”

Ultimately, what worked better was when a nurse or physician would call the GEDI nurse, specify the concern, and request an evaluation, Dresden notes.

“Those were the consults that helped the most, so after the funding we received through [a Medicare Health Care Innovation Award] ... ended, we modified the program very slightly, and removed the ISAR [screening] at triage,” he says.

However, Dresden stresses that using the ISAR for a period helped establish a baseline for the types of patients who might benefit from further evaluation by a GEDI nurse.

“As we learned what [the GEDI WISE approach] can do and who it can help, it helped to change the culture in the ED,” he says. “But after our nurses and physicians became more aware of the types of things that can put older patients at risk, we found that the screen itself wasn’t all that helpful.”

Northwestern Memorial has developed its own training program for GEDI nurses. Typically, these nurses spend time in a skilled nursing facility, assisted living environment, and a geriatric clinic; they also conduct rounds with a palliative care team, Dresden says.

“[Additionally], we have geriatricians, pharmacists, and social workers who give didactic sessions in a classroom setting, so there is a wide mix of classroom and experiential learning,” he says. Dresden adds that one or two GEDI nurses are available in the ED at Northwestern Memorial between 8 a.m. and 10 p.m., Monday through Friday.

Training for transitional care nurses is delivered in a similar fashion at Mount Sinai, Hwang says.

“They have an orientation with regards to protocols and they have education modules [that focus on] communicating and working with older adults,” she says. “At some of our other sites, there is a two- to three-week curriculum where [the nurses] rotate through outpatient geriatric clinical services just to see what it is like to work in an outpatient geriatric clinic, palliative care clinic, and, more specifically, to get training on the assessments that are done.”

Consult Guidelines

Dresden’s advice to other EDs interested in improving care for older adults is to start by focusing on the Geriatric ED Guidelines. “It is a good list of how to improve care,” he says. “The main thing is identifying patients who are at risk and identifying ways to [address] those risks.”

This can occur in various ways, but it will require resources. “We found that emergency physicians and emergency nurses are overloaded with many tasks,” Dresden advises. “I think if we had just said, ‘Here are all these protocols that we are going to put in place for our bedside nurses and our emergency physicians,’ I don’t know that it would have been as successful as [our program] is, so having a separate team that comes along and works alongside [the physicians and nurses] really helps.”

Another step that can be helpful is to work with colleagues who are exploring similar innovations. For instance, Dresden notes that Northwestern Memorial is part of the Geriatric Emergency Department Collaborative, a group that was established by the Hartford Foundation and West Health. “We are working with that group on disseminating models like this throughout the country,” he adds.

Dresden explains that focusing on the care team rather than creating a designated space for the care of older adults may make implementing improvements in this area somewhat easier for many EDs. “It makes [the model] a lot more flexible,” he says.

Hwang agrees that the focus should be on the care that is delivered, rather than the space. In fact, she notes that while Mount Sinai Hospital contains a designated 14- to 20-bed unit that is equipped with senior-friendly features, the geriatrics care team often sees patients in the main ED when the space is full. Also, there are times when the unit must be flexed into use for younger patients, too, which has been the case this winter.

“Especially with the flu, there has been a lot of crowding and boarding of patients in the ED, so the space has now been overrun by boarding patients,” she says. Hwang reiterates that the designated space is not what makes the geriatric ED, but rather the assessments and care that address the needs of older adults — aspects that are evident throughout the main ED, too. “That is what really makes a geriatrics ED,” she adds.

Repurpose Existing Resources

When taking this approach, hospitals should assess what resources they already have in place, Hwang advises. Some staff may be able to be repurposed to provide geriatrics care in a way that is effective and efficient.

“If your ED does not already have a social worker or access to transitional care services, maybe those services already exist in your hospital,” she says. “[Look at how] the ED can bridge with those services and how the ED might leverage technicians.”

Hwang notes that some Veterans Administration hospitals are using technicians to fulfill some of the assessments that transitional care nurses typically perform. For example, technicians might conduct a fall risk assessment in consultation with the emergency physician.

“It is taking into account that bigger picture of what is going to happen to the patient, whether they will be admitted or discharged,” she says. “And that additional information about fall risk or their medications or their functional status can help facilitate transitions of care.” Avoiding hospitalization is not just a money-saving exercise, Hwang stresses.

“People sometimes think if they are hospitalized it will be better for them, but it is actually not — especially in the case of older adults,” she says, noting that older adults often become more frail following an inpatient discharge. “If a patient doesn’t need to be hospitalized, then we should try to avoid it.”

Now that it has been shown that transitional care nurses with geriatric training can reduce hospitalization among older adults who present to the ED, innovators are looking for additional ways to improve care to this patient population. For instance, at Northwestern Memorial, Dresden just implemented a universal screening program for delirium for all patients 65 years of age and older, and he is looking into developing a protocolized screening approach for elder abuse.

“These are major problems in EDs throughout the country — delirium and elder abuse,” he says. “They are hard to find, so those are new areas we are looking to explore ... so that those patients aren’t slipping through the cracks.”

REFERENCE

1. Hwang U, Dresden SM, Rosenberg MS, et al. Geriatric emergency department innovations: Transitional care nurses and hospital use. J Am Geriatr Soc 2018 Jan 10. doi:10.1111/jgs.15235. [Epub ahead of print].