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ED-Based Transitional Care Nurses Help Older Patients Avoid Admissions

Is your emergency department (ED) struggling to reduce unnecessary admissions of older patients? Three large urban hospitals appear to have come up with a way to do that.

A report in the Journal of the American Geriatrics Society describes how Mount Sinai Health System in New York City; St. Joseph's Regional Medical Center in Paterson, NJ; and Northwestern Memorial Hospital in Chicago have successfully used transitional care nurses in the ED to provide both higher quality care and to avoid admissions.

Researchers from Mt. Sinai point to the Geriatric Emergency Department Innovations in Care through Workforce, Informatics, and Structural Enhancements (GEDI WISE) model as a key factor. The program includes an ED-based transitional care nurse program — involving nurse practitioners, specialized emergency nurses, and social workers — to identify patients with geriatric-specific health needs and coordinate their transition from ED to home.

The study focused on 57,000 patients age 65 years and older who presented between 2013 and 2015 at all three medical centers. One in 10 of them was evaluated by a transitional care nurse for cognitive function, delirium, agitation, functional status, falls risk, and caregiver strain. A score was developed based on the assessment, which, in turn, determined level of ED care provided.

Analysis indicates that, for patients with any symptoms, triage severity, or illness severity, those seen by a transitional care nurse were 10% more likely to be discharged, compared to similar patients receiving usual care.

In addition, at two of the three centers, inpatient admission rates remained lower over the next month for patients treated by a transitional care nurse and discharged from the ED.

“These findings will allow hospitals and health care systems to focus on better geriatric emergency care programs for a vulnerable, aging population,” explained lead investigator Ula Hwang, MD, associate professor of emergency medicine and of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai. “At a time when the national average for emergency department admissions with older adults is on the rise, programs that can reduce hospitalization risk are crucial.”

Avoiding hospitalization keeps older adults away from risks such as adverse drug effects, falls, cognitive decline, and ulcers, the study notes. Furthermore, researchers found that more than 30% of older adults develop a disability after an acute admission and often never return to their previous functional level.

“An emergency department (ED) visit is often described as a sentinel event signifying a breakdown in care coordination for older adults,” researchers note. “With the ED at the crossroads of multiple healthcare settings, it has been described as ‘a portal of entry to inpatient care.’ Both hospitalization and being discharged from the ED carry significant risks for older adults, including iatrogenic complications, functional and cognitive decline, and loss of independence. This highlights the importance of greater care to support transitions from the ED.”