This article appears in Salute to Nurses 2018.
A relatively new program that uses transitional-care nurses to identify specific health needs of geriatric patients in emergency rooms is cutting their rates of hospitalizations and leading to better medical outcomes.
About one-third of patients older than 65 who visit an emergency room nationwide end up being hospitalized, but this new program can cut that rate, according to a study by researchers from Mount Sinai Health System in New York City; St. Joseph’s Regional Medical Center in Paterson, New Jersey; and Northwestern Memorial Hospital in Chicago.
The Geriatric Emergency Department Innovations in Care through Workforce, Informatics and Structural Enhancements, or GEDI WISE, program launched in 2012. At the three hospitals that were part of the study, a patient was 10 percent more likely to be discharged from the hospital when compared with the same type of patient not seen by such a transitional nurse.
Interventions initiated during an older patient’s arrival in the emergency room have a significant impact on care, said lead investigator Ula Hwang, M.D., associate professor of emergency medicine and of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai.
“Specifically trained advanced-practice nurses target older adults through questions and assessments to see if they can face a safe discharge,” Hwang said.
While a patient who has suffered cardiac arrest is not going to be sent home, others who may have come in for a cough or a fall may be. In the past, though, many of these individuals were “social admissions,” Hwang said, meaning no safe discharge arrangements could be made for the patient, so he or she was hospitalized.
Transitional-care nurses assess patients for cognitive function, delirium, agitation, functional status, falls risk and caregiver strain. A score-based assessment determines the extent of care that will be delivered in the emergency department, Hwang said.
Nurses ask questions to understand the bigger picture of what’s going on in a patient’s life, Hwang said: What medications are you taking, and do you have other underlying medical conditions? What level of social support do you have at home? Can you care for yourself or do you need help?
If discharged, patients will receive follow-up calls, receive counseling from a social worker or sometimes be transferred to a nursing home.
Ahead of a trend?
Programs like GEDI WISE are trending nationwide. In 2013, the American College of Emergency Physicians, American Geriatrics Society and Society for Academic Emergency Medicine joined with the Emergency Nurses Association to develop and publish the Geriatric Emergency Department Guidelines. In 2017 the first ACEP Geriatric Emergency Accreditation became available for such ERs.
“Bottom line, the population is aging. Hospitals and health-care systems have to focus on this vulnerable aging population. 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,” Hwang said.
Hospitals can be a dangerous place for older adults, Hwang said. Some risks include adverse drug effects, falls, cognitive decline and ulcers. More than 30 percent of older adults develop a hospital-associated disability after an acute admission, and many do not return to their previous functional state.
Nurses are a central part of making programs like this work, Hwang said. “They play an interdisciplinary role working” with other medical professionals including social workers, pharmacists, doctors, physical therapists and home health aides, she said.