Emergency plans, teletriage decrease patient visits to emergency department

Thorough, repetitive patient and staff education produces results

It's the middle of the night and the patient you admitted last week is having difficulty breathing. Because the nurse has only seen the patient once, and because of the time of day, and because both the patient and the caregiver are not sure what to do, they go to the emergency room.

This emergency room visit and a possible rehospitalization could have been prevented with a well-designed patient emergency plan as well as an effective teletriage system.

All home health agencies have some form of patient emergency plan and a teletriage process in place, but some agencies handle processes better than others, points out Eve Esslinger, BSN, MS, project manager for Home Health Quality Improvement Organization Support Center-Quality Insights of Pennsylvania in Harrisburg. "You can decrease visits to the emergency department and rehospitalizations by making sure that patients know when to call you," she says. In order to decrease those visits, agencies should take a careful look at their processes, policies, and education, she suggests.

Reducing hospitalizations was the reason that managers at Lutheran Home Care Services in Chambersburth, PA, evaluated their own patient emergency plans and teletriage system, says Kathy Johnson, RN, director of the home care agency. "We reviewed our data against the CMS data of other agencies to set priorities for quality improvement programs," she explains. "We identified reduction of rehospitalizations and emergency department visits as a high priority." One year later, the agency has seen a drop in the number of patient visits to the emergency department and subsequent rehospitalizations, she adds.

As Johnson's agency staff members reviewed charts of patients who had made trips to the emergency department or were rehospitalized, they looked at what happened immediately before the trip to the hospital. Not only did the agency determine what initiated the patient's decision to seek help, but staff members also documented whether the patient called the agency and, if so, whether the nurse sent them to the emergency department. "We also looked at the date of admission for the patient," she adds.

"We did find a few trends in our study," says Johnson. "We found that many times patients just did not call us, especially if they were relatively new to home care," she says. "We also found that nurses who were newer to home health and were juggling a number of scheduled visits would not be able to visit the patient for several hours, so the patient would go to the emergency department."

Although plans to improve staff education and the teletriage process were made, the agency also improved the patient emergency plan process, says Johnson. "We realized that the first step in reducing hospitalizations is to get the patient to call us before heading to the hospital.

"We always had information in our admission packet about when to call the home health agency, but we cover so much information with the patient at the first visit, it was hard for patient to remember," admits Johnson. "Now, we use a laminated, three-column card that describes symptoms, when to call the home health agency, and when to call 911 or go to the hospital," she says. At the first visit, nurses not only show the card to the patient and explain how to use it, but they also post it on the patient's refrigerator, she points out. Posting the card on the refrigerator not only makes the information easy to find but also emphasizes the importance of the information to the patient, she says.

"Of all the tools produced for the Home Health Quality Improvement National Campaign, I have had more people tell me they like the patient emergency plan tool the most," says Esslinger. "The symbols catch people's attention and the format is easy to read and understand," she says. Although the emergency plan tool has been successfully used in many agencies, Esslinger does suggest that agencies modify it as needed to fit their own patients' needs. "It is available as a modifiable document so agencies may make additions, deletions, or changes," she adds.

Educate all staff members

Once patients know when to call the home health agency, make sure that your staff are well trained and the process is well defined, suggests Esslinger. "When patients call, they should not be put on hold for a long period of time," she says. "They should be connected to a nurse if the patient is calling with a health-related issue."

Be sure that your teletriage process works well 24 hours a day, points out Esslinger. "Some agencies find that their on-call coverage outside of normal business hours works well, but teletriage during the business day is less smooth," she says. Although more employees are available during normal business hours, nurses that normally see the patient may be tied up with visits to other patients, or receptionists may not have clearly defined methods of getting the patient connected to a nurse. "All agency employees should be familiar with the process and know who can take the patient's call," she adds.

"Everyone needs to be on the same page," agrees Johnson. "Some of our patients only receive therapy visits so the therapist reviews the emergency plan and posts the card to make sure the patient knows whom to call," she points out. "Our home health aides are also trained to reinforce the emergency plan and to call a nurse if they notice symptoms that require attention."

Johnson's agency also has improved the teletriage process during day. The night call process uses an answering service that has the capability to immediately forward the patient to the nurse's home or cell phones so there was no delay in reaching a nurse. During the daytime, however, nurses could not answer their cell phones if they were with patients, Johnson points out. "Now, our receptionist receives the call, then while the patient is on hold, finds the supervisor of the territory in which the patient lives and transfers the patient to the supervisor," she says. "The supervisor talks with the patient to determine if there is need for a visit, if there is something that can be done over the phone to alleviate the patient's concern, or if there is a need to call a physician or send the patient to the hospital.

"We also require nurses to get supervisor approval before directing patients to go to the emergency department," says Johnson. This step gives the supervisor an opportunity to make sure that there is a legitimate reason for the emergency department visit or to schedule another nurse to make a visit to the patient if the primary nurse is unable to do so due to her schedule.

"We did enhance our staff education," says Johnson. All employees learn about the emergency care plan and the teletriage process in orientation but nurses do not take a call for at least 90 days after they are employed, she points out. "Prior to taking call after hours, a nurse must attend a four-hour class that reviews the teletriage process and the tools and resources available to help nurses make decisions during triage."

Keep process simple, part of normal routine

The key to successful implementation of any change in home health is to keep the change as simple as possible, suggests Johnson. "We have so many documentation requirements and processes for our nurses to handle that we need to make sure changes help them in their job rather than add to the complexity," she explains. Having the patient emergency plan card laminated and easy to post on the refrigerator was simple and makes it easy for nurses to review with patients at each visit, she says. "Providing decision-support tools also simplifies the process and gives nurses information that is easy to access via laptop."

Make sure, also, that all employees understand the reason for the change, suggests Esslinger. Explain what your reasons are for making the change and report back to staff members results of the change, she says.

Johnson not only explains how rehospitalizations and visits to the emergency department affect the home health agency's bottom line but she also posts regular reports, divided by office location, about rehospitalization and emergency department visit rates on a bulletin board in each office. "We also talk about the patient emergency plans and teletriage in team meetings to review the process and identify ways to improve it," she adds.

Even with staff members explaining the emergency plan and reminding patients of the process at each visit, there are times that you may not be able to control the situation, points out Johnson. There are two situations that arise in Johnson's area that sometimes result in visits to the emergency department even if the home health agency has done everything it can.

"Because our local hospital has hospitalists on staff, primary care physicians in our area are less likely to leave room in the daily schedules for immediate visits from patients," says Johnson. Even if the home health nurse assesses the patient at the home and calls the physician to recommend that he or she see the patient, the physician is likely to send the patient to the emergency department to be seen by a hospitalist. If the patient does need to see a physician and the family physician won't see the patient immediately, there really is no choice but to send the patient to the emergency department, she adds.

The other situation that occurs is when out-of-town family members visit the patient, points out Johnson. When family members have not seen the patient in a long time, they may be surprised to see weight loss, less mobility than they remember, or other changes in their condition, she says.

"Even patients who speak regularly to family members don't explain every detail of their condition, so symptoms or conditions that are normal for the patient may seem alarming to a family member who hasn't seen the patient in a while," she explains. The family member's first reaction is to "find out what's going on and get the family member checked" even if the patient is seen by a home health nurse regularly, she adds.

To address this situation, nurses remind patients of their emergency plan and contact numbers for the home health agency if they know family members are visiting. Johnson suggests that by saying, "It's wonderful that your daughter's coming to visit this weekend. Remember that if she has any questions about your health or your care, she can call the agency any time.

Be sure to show her the refrigerator card with our phone numbers," you get an opportunity to answer questions and help the patient avoid an unnecessary trip to the emergency department.

Sources & resources

For more information about patient emergency plans and teletriage, contact:

  • Eve Esslinger, BSN, MS, project manager, Home Health Quality Improvement Organization Support Center-Quality Insights of Pennsylvania, 2188 Crawford Road, Harrisburg, PA 17815. Phone: (877) 346-6180, ext. 7685. E-mail: eesslinger@wvmi.org.
  • Kathy Johnson, RN, director, Lutheran Home Care Services, 2700 Luther Drive, Chambersburg, PA 17201. Phone: (717) 217-3529. E-mail: Kjohnson@lutheranhomecare.org.
  • For a copy of the patient emergency plan, and other tools and plans developed by the Home Health Quality Improvement National Campaign, go to www.homehealthquality.org. Select "For home health agencies" on the left navigational bar, then choose "intervention packages" and scroll down to April 2007 to select "Patient emergency plan." This page contains links to documents related to patient emergency plans, including tools such as the patient emergency plan form.
  • For access to decision-making tools that can be used in teletriage, go to www.homehealthquality.org. Select "For home health agencies" on the left navigational bar, then choose "additional resources." Scroll down to "Home Health Telephone Reference 2006/2007." This link will take you to the MedQIC site. On the right navigational bar scroll down to "Teletriage Decision Support Tools" to download.