Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use

Ula Hwang, Scott M Dresden, Mark S Rosenberg, Melissa M Garrido, George Loo, Jeremy Sze, Stephanie Gravenor, D Mark Courtney, Raymond Kang, Carolyn W Zhu, Carmen Vargas-Torres, Corita R Grudzen, Lynne D Richardson, GEDI WISE Investigators, Ula Hwang, Scott M Dresden, Mark S Rosenberg, Melissa M Garrido, George Loo, Jeremy Sze, Stephanie Gravenor, D Mark Courtney, Raymond Kang, Carolyn W Zhu, Carmen Vargas-Torres, Corita R Grudzen, Lynne D Richardson, GEDI WISE Investigators

Abstract

Objectives: To examine the effect of an emergency department (ED)-based transitional care nurse (TCN) on hospital use.

Design: Prospective observational cohort.

Setting: Three U.S. (NY, IL, NJ) EDs from January 1, 2013, to June 30, 2015.

Participants: Individuals aged 65 and older in the ED (N = 57,287).

Intervention: The intervention was first TCN contact. Controls never saw a TCN during the study period.

Measurements: We examined sociodemographic and clinical characteristics associated with TCN use and outcomes. The primary outcome was inpatient admission during the index ED visit (admission on Day 0). Secondary outcomes included cumulative 30-day admission (any admission on Days 0-30) and 72-hour ED revisits.

Results: A TCN saw 5,930 (10%) individuals, 42% of whom were admitted. After accounting for observed selection bias using entropy balance, results showed that when compared to controls, TCN contact was associated with lower risk of admission (site 1: -9.9% risk of inpatient admission, 95% confidence interval (CI) = -12.3% to -7.5%; site 2: -16.5%, 95% CI = -18.7% to -14.2%; site 3: -4.7%, 95% CI = -7.5% to -2.0%). Participants with TCN contact had greater risk of a 72-hour ED revisit at two sites (site 1: 1.5%, 95% CI = 0.7-2.3%; site 2: 1.4%, 95% CI = 0.7-2.1%). Risk of any admission within 30 days of the index ED visit also remained lower for TCN patients at both these sites (site 1: -7.8%, 95% CI = -10.3% to -5.3%; site 2: -13.8%, 95% CI = -16.1% to -11.6%).

Conclusion: Targeted evaluation by geriatric ED transitions of care staff may be an effective delivery innovation to reduce risk of inpatient admission.

Keywords: admission; emergency department; transitions of care.

© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.

Figures

Figure 1.
Figure 1.
Entropy balancing resulted in improved covariate balance (smaller absolute value of standardized difference) across treatment and comparison groups for each site

References

    1. Chen PW. Emergency Rooms Are No Place for the Elderly In: Doctor and Patient. New York: New York Times; 2014.
    1. Clancy CM, Eisenberg JM. Emergency medicine in population-based systems of care. Ann Emerg Med 1997;39:800–3.
    1. Coleman EA, Eilertsen TB, Kramer AM, Magid DJ, Beck A, Conner D. Reducing emergency visits in older adults with chronic illness. A randomized, controlled trial of group visits. Eff Clin Pract 2001;4:49–57.
    1. Morganti KG, Bauhoff S, Blanchard JC, et al. The Evolving Role of Emergency Departments in the United States. Santa Monica, CA: RAND Corporation; 2013.
    1. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348:2635–45.
    1. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003;362:1225–30.
    1. Hwang U, Shah MN, Han JH, Carpenter CR, Siu AL, Adams J. Transforming Emergency Care for Older Adults. Health Aff 2013;32:2116–21.
    1. Corsonello A, Pranno L, Garasto S, Fabietti P, Bustacchini S, Lattanzio F. Potentially inappropriate medication in elderly hospitalized patients. Drugs Aging 2009;26 Suppl1:31–9.
    1. Covinsky KE, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: Increased vulerability with age. J Am Geriatr Soc 2003;51:451–8.
    1. Sager MA, Franke T, Inouye SK, et al. Functional outcomes of acute medical illness and hospitalization in older persons. Arch Intern Med 1996;156:645–52.
    1. Hirsch CH, Sommers L, Olsen A, mullen L, Winograd CH. The natural history of functional morbidity in hospitalized older patients. J Am Geriatr Soc 1990;38:1296–303.
    1. Wakefield BJ, Holman JE. Functional trajectories associated with hospitalization in older adults. West J Nurs Res 2007;29:161–77.
    1. Lakhan P, Jones M, Wilson A, Courtney MC, Hirdes J, Gray LC. A prospective cohort study of geriatric synrdomes among older medical patients admitted to acute care hospitals. J Am Geriatr Soc 2011;59:2001–8.
    1. Nagurney JM, Fleischman W, Han L, Leo-Summers L, Allore HG, Gill TM. Emergency Department Visits Without Hospitalization Are Associated with Functional Decline in Older Persons. Ann Emerg Med 2017;69:426–33.
    1. Health Care Innovation Award project profiles [Internet]. 2012. (Accessed August 18, 2014, at , .)
    1. Geriatric Emergency Department Guidelines. 2014. (Accessed June 25, 2014, at .)
    1. Aldeen AZ, Courtney MC, Lindquist LA, Dresden SM, Gravenor SJ. Geriatric Emergency Department Innovations: Preliminary Data for the Geriatric Nurse Liaison Model. J Am Geriatr Soc 2014;62:1781–5.
    1. Grudzen C, Richardson LD, Baumlin KM, et al. Redesigning geriatric emergency care may have helped reduce admissions of older adults to intensive care units. Health Aff (Millwood) 2015;34:788–95.
    1. Erkinjuntti T, Sulkava R, Wikstrom J, Autio L. Short Portable Mental Status Questionnaire as a screening test for dementia and delirium among the elderly. J Am Geriatr Soc 1987;35:412–6.
    1. Borson S, Scanlan JM, Chen PJ, et al. The Mini-Cog as a screen for dementia: Validation in a population-based sample. J Am Geriatr Soc 2003;51:1451–4.
    1. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Annals of internal medicine 1990;113:941–8.
    1. Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale. Am J Resp Critical Care Med 2002;166:1338–44.
    1. Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: Validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001;286:2703–10.
    1. Katz S Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. J Am Geriatr Soc 1983;31:721–7.
    1. Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142–8.
    1. Parry C, Mahoney E, Chalmers SA, Coleman EA. Assessing the quality of transitional care: further applications of the care transitions measure. Medical care 2008;46:317–22.
    1. McCusker J, Bellavance F, Cardin S, Trepanier S, Verdon J, Ardman O. Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool. J Am Geriatr Soc 1999;47:1229–37.
    1. Wuerz R, Milne L, Eitel D, Gilboy N. Reliability and validity of a new five-level triage instrument. Acad Emerg Med 2000;7:236–42.
    1. Hainmuller J Entropy Balancing for Causal Effects: A Multivariate Reweighting Method to Produce Balanced Samples in Observational Studies. Political Analysis 2012;20:25–46.
    1. Watson SK, Elliot M. Entropy balancing: a maximum - entropy reweighting scheme to adjust for coverage error. Qual Quant 2016;50.
    1. Zhao Q, Percival D. Entropy Balancing is Doubly Robust. J Causal Inference 2016;5:10.1515/jci-2016-0010.
    1. Harvey RA, Hayden JD, Kamble PS, Bouchard JR, Huang JC. A comparison of entropy balance and probability weighting methods to generalize observational cohhorts to a population: a simulation and empirical example. Pharmacoepideiol Drug Saf 2017;26:368–77.
    1. Charlson M, Pompei P, Ales K, MacKenzie C. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–83.
    1. Stuart EA. Matching Methods for Causal Inference: A Review and Look Forward. Statistical Science 2010;25:1–21.
    1. Funk MJ, Westreich D, Wiesen C, Sturmer T, Brookhart MA, Davidian M. Doubly Robust Estimation of Causal Effects. Am J Epidemiol 2011;173:761–7.
    1. Pitts SR, Carrier ER, Rich EC, Kellermann AL. Where Americans get acute care: increasingly, it not at their doctor’s office. Health Aff (Millwood) 2010;29:1620–9.
    1. Kocher KE, Ayanian JZ. Flipping the Script - A Patient-Centered Approach to Fixing Acute Care. N Eng J Med 2016;375:915–7.
    1. National Hospital Ambulatory Medical Care Survey: 2012 Emergency Department Summary Tables. U.S. Department of Health and Human Services, 2012. (Accessed December 9, 2016, at .)
    1. Tricco AC, Antony J, Ivers NM, et al. Effectiveness of quality improvement strategies for coordination of care to reduce use of health care services: a systematic review and meta-analysis. CMAJ 2014;186:E568–78.
    1. McCusker J, Verdon J. Do geriatric interventions reduce emergency department visits? A systematic review. J Gerontol A Biol Sci Med Sci 2006;61:53–62.
    1. Hastings SN, Heflin MT. A systematic review of interventions to improve outcomes for elders discharged from the emergency department. Acad Emerg Med 2005;12:978–86.
    1. Caplan G, Williams A, Daly B, Abraham K. A randomized, controlled trial of comprehensive geriatric assessment and mutlidisciplinary intervention after discharge of elderly from the emergency department --the DEED II study. J Am Geriatr Soc 2004;52:1417–23.
    1. Gagnon AJ, Schein C, McVey L, Bergman H. Randomized controlled trial of nurse caes managmeent of frail older people. J Am Geriatr Soc 1999;47:1118–24.
    1. Guttman A, Afilalo M, Guttman R, et al. An emergency department-based nurse discharge coordinator for elder patients: does it make a difference? Acad Emerg Med 2004;11:1318–27.
    1. Ellis G, Marshall T, Ritchie C. Comprehensive geriatric assessment in the emergency department. Clin Interv Aging 2014;9:2033–43.
    1. Galenkamp H, Deeg DJ, dr Jongh RT, Kardaun JW, Huisman M. Trend study on the association between hospital admissions and the health of Dutch older adults (1995–2009). JBMJ Open 2016;6:e011967.
    1. Fingar KR, Barrett ML, Elixhauser A, Stocks C, Steiner CA. Trends in Potentially Preventable Inpatient Hospital Admissions and Emergency Department Visits. Rockville, MD: Agency for Healthcare Research and Quality; November 2015.

Source: PubMed

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