NEW YORK (Reuters Health) – Evaluation by a transitional care nurse (TCN) in the emergency department (ED) may reduce the risk of inpatient admission for patients 65 or older, researchers say.
“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,” according to Dr. Ula Hwang of Icahn School of Medicine at Mount Sinai in New York City and colleagues.
“This highlights the importance of greater care to support transitions from the ED,” they note.
To investigate the effect of seeing a TCN during an ED visit, the team conducted a prospective observational study of individuals 65 or older who visited a hospital that participated in the GEDI WISE program (http://bit.ly/2DzcFqt), a multidisciplinary, U.S. Centers for Medicare & Medicaid Services-supported collaboration among three hospitals that have geriatric EDs targeting older adults.
The TCN intervention included evaluations of function, cognition, physical status, fall risk, medical complexities and other parameters by emergency nurses or nurse practitioners who are trained to facilitate care transitions of older adults in the ED.
For the study, the intervention was the first TCN contact. Controls did not see a TCN during the study period.
“We hypothesized that individuals who saw a TCN would have lower risk of admission, lower risk of subsequent admission, but might have more ED revisits,” the authors state.
As reported in the Journal of the American Geriatrics Society, online January 10, a total of 57,287 patients were included in the analyses. A TCN saw 5,930 (about 10%), of whom 42% were admitted to the hospital.
After adjustment for potential selection bias, patients with a TCN contact had a significantly lower risk of inpatient admission – specifically, a 9.9% lower risk at site 1; a 16.5% lower risk at site 2; and a 4.7% lower risk at site 3 – compared with patients discharged from the ED without a 72-hour ED revisit.
As anticipated, participants who had a TCN contact had a greater risk of a 72-hour ED revisit at two sites: 1.5% greater at site 1 and 1.4% greater at site 2. However, the revisit risk was similar to that of controls at site 3.
Similarly, the risk of any inpatient admission within 30 days after the first ED visit was significantly lower for TCN patients at sites 1 and 2, but not at site 3.
As the multicenter study showed, Dr. Hwang told Reuters Health, “the intervention can be scaled to all different types of hospitals. The implementation model varied by site based on resources and needs of the hospitals and their patient population.”
“The next research steps,” she said by email, “are to better understand what the TCN nurses did at each site and understand the degree to which they provided and facilitated care transitions for individual participants.”
“By determining which of the care transition processes and care coordination elements are associated with better outcomes, we could then replicate this in a randomized control trial in the ED setting to demonstrate causal effect,” she concluded.
Dr. Lauren Southerland, Director of Geriatric Emergency Care at The Ohio State University Wexner Medical Center in Columbus, commented, “This group looked at 72-hour revisits to the ED, which is one way to measure if patients have been discharged inappropriately.”
“They found in two of the three sites, revisits to the ED were the same or lower, and in one site it was slightly higher,” she said in an email to Reuters Health. “So we cannot say for sure if avoiding admissions for these patients is the best path.”
“However, as there wasn’t a definite trend, we think that keeping older adults away from the illnesses, bedrest and immobility, and confusing atmosphere of the hospital is usually a good thing,” she acknowledged.
“Additionally, these patients had very comprehensive geriatric evaluations, looking for unrecognized dementia, delirium, frailty, fall risk, signs of elder abuse, and social isolation in addition to the typical ED medical workup,” she observed. “Therefore, they may have been safer than the patients admitted to hospital without this comprehensive approach to care.”
“Not every ED will be able to staff geriatric-trained nurses or nurse practitioners to assess patients,” Dr. Southerland continued. “However, there are other ways to offer similar services, and social workers and case managers can and do perform many of these assessments.”
She added that the American College of Emergency Physicians “is starting a process to assess how well EDs care for older adults, called Geriatric Emergency Department Accreditation.” (http://bit.ly/2Dz6yCu)
“I think this process has gained the focus of many people in emergency medicine, and we will see even more data on great innovations coming down the pipeline,” she concluded.
SOURCE: http://bit.ly/2DKe9Ld
J Am Geriatr Soci 2018.
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