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Transitional care nurses in A&E ‘reduce older inpatient admissions’

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Basing specialist nurses trained in “transitional care” within the accident and emergency department can significantly reduce the number of admissions among older patients, according to a US study.

It revealed that elderly patients seen on arrival by a transitional care nurse in A&E were less likely to be subsequently admitted to the hospital.

“To our knowledge, this is the first study to show a significant decrease in hospitalisation risk”

Study authors

Researchers looked at the impact of an initiative called the Geriatric Emergency Department Innovations in Care through Workforce, Informatics, and Structural Enhancements (GEDI WISE).

As previously reported by Nursing Times, the model is being tried out at Mount Sinai Health System in New York City, along with two other large urban hospitals in the US – St Joseph’s Regional Medical Center in New Jersey, and Northwestern Memorial Hospital in Chicago.

GEDI WISE involves a transitional care nurse based in A&E to identify patients with geriatric-specific health needs and to co-ordinate their transition from the emergency department to home.

Similar initiatives to reduce admissions have been suggested or tried in the UK, sometimes using primary care nurses based in A&E or a more intensive triage process than normal.

In the new study, US researchers evaluated the effects of transitional care nurses on more than 57,000 patients aged 65 and older who arrived between 2013 and 2015 at all three of the hospitals.

The study authors noted that the intervention consisted of “emergency nurses trained to facilitate care transitions of older adults in the emergency department to the community with the goal of avoiding inpatient admission when possible”.

“This included evaluation of functional and cognitive impairment, physical frailty, and medical complexities common in older adults that often limit their ability to navigate the outpatient healthcare system,” said the researchers.

“At all sites, the transitional care nurse was a nurse or nurse practitioner,” they stated in the Journal of the American Geriatrics Society.

The researchers said that 10% of patients in the study were seen by a transitional care nurse, who assessed for cognitive function, delirium, agitation, functional status, falls risk, and caregiver strain.

The nurse’s score-based assessment determined the extent of A&E care provided. For any given presentation of symptoms and illness severity, those seen by a transitional care nurse were more likely to be discharged than admitted, when compared to the same type of patient not seen by one.

“Programmes that can reduce hospitalisation risk are crucial” 

Ula Hwang

At all three hospitals, individuals who saw a transitional care nurse had on average a 10% lower chance of being admitted, said the researchers. At two of them, inpatient admission rates remained lower over the subsequent 30 days for patients treated by a transitional care nurse and discharged from A&E.

The study authors said: “To our knowledge, this is the first study to show a significant decrease in hospitalisation risk through an emergency department-based geriatric assessment and care transitions programme.

They added: “Targeted evaluation by clinically trained nursing staff focused on improving the emergency department transitions of care may be an effective delivery innovation to reduce likelihood of hospital admission, subsequent complications, loss of function and independence associated with hospitalisations, and costly inpatient care.”

Lead study author Dr Ula Hwang, associate professor of emergency medicine, geriatrics and palliative medicine at Mount Sinai Hospital, said: “These findings will allow hospitals and healthcare systems to focus on better geriatric emergency care programmes for a vulnerable, aging population.

“At a time when the [US] national average for emergency department admissions with older adults is on the rise, programmes that can reduce hospitalisation risk are crucial,” she added.

The researchers noted that further study was needed to evaluate A&E revisit rates among older patients seen by transitional care nurses.

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