Transitional Care Nurses in the Geriatric ED Reduce Risk of Inpatient Admissions

Geriatric patients seen by transitional care nurses in the emergency department (ED) are less likely to be admitted to the hospital, according to a study conducted at the Icahn School of Medicine at Mount Sinai and published in the Journal of the American Geriatrics Society. These findings show that interventions initiated during an older patient's arrival through the ED can have a significant impact on care.

According to the Emergency Care Research Institute, geriatric adults (65 and older) account for up to 25% of all ED visits, but their needs may not be met in a general ED. Programs like the Geriatric Emergency Department Innovations in Care through Workforce, Informatics, and Structural Enhancements (GEDI WISE) have been developed to meet these challenges. It's a model used at three large urban hospitals: Mount Sinai Health System in New York City; St. Joseph's Regional Medical Center in Paterson, New Jersey; and Northwestern Memorial Hospital in Chicago.

GEDI WISE includes an ED-based transitional care nurse program to identify patients with geriatric-specific health needs and coordinate their transition from ED to home. Transitional care nurses include nurse practitioners, ED nurses, and social workers.

In this study, 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 medical centers. Ten percent of these patients were seen by a transitional care nurse, who assessed for cognitive function, delirium, agitation, functional status, falls risk, and caregiver strain. Their score-based assessment determined the extent of ED care delivered. For any given presentation of symptoms, triage severity, and illness severity, the ED was more likely able to discharge and not admit those patients seen by a transitional care nurse when compared with the same type of patient not seen by such a nurse.

At all three medical centers, individuals who saw a transitional care nurse had on average a 10% lower chance of being admitted. At two of the three centers, inpatient admission rates remained lower over the subsequent 30 days 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," says lead investigator Ula Hwang, MD, an 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."

Hospitalization of older adults carries risks, such as adverse drug effects, falls, cognitive decline, and ulcers. More than 30% of older adults develop a hospital-associated disability after an acute admission, and many do not return to their previous functional state.

Additionally, researchers say reducing inpatient admissions of older patients leads to cost savings for hospitals that are moving from a fee-for-service model to value-based care. While hospital admittance is sometimes necessary, health care providers can lower costs by providing the bulk of care in ambulatory clinics or in a patient's home.

Further study is needed to evaluate ED revisit rates among geriatric patients seen by transitional care nurses.