Understanding registered nurse decision-making, communication and care delivery between emergency departments and residential aged care facilities: A research protocol.

OBJECTIVES: Nursing staff in residential aged care facilities (RACF)s often make decisions about the transfer of residents to the emergency department (ED). This paper describes the protocol of a study that aims to understand decision-making process utilised by RACF registered nurses (RNs) and to explore the perceptions of RNs about the decision and communication process between RACF and ED. METHODS: The proposed mixed-method study will survey and interview RACF RNs to understand their decision to transfer a resident and collect information about older people referred to the ED. Data collection will involve telephone survey, ED information system (EDIS) data and semistructured interviews. RESULTS: The project outcomes will provide an understanding of existing ED service provision, communication between facilities and the reasons for transfer of older person to ED. This may inform redesign in communication processes between the ED and local RACFs and outreach care from the ED to RACFs.

The Geriatric Emergency Department Intervention model of care: a pragmatic trial.

BACKGROUND: To evaluate a Geriatric Emergency Department Intervention (GEDI) model of service delivery for adults aged 70 years and older. METHODS: A pragmatic trial of the GEDI model using a pre-post design. GEDI is a nurse-led, physician-championed, Emergency Department (ED) intervention; developed to improve the care of frail older adults in the ED. The nurses had gerontology experience and education and provided targeted geriatric assessment and streamlining of care. The final format included 2.4 full time equivalent nurses working 7 days from 0700 h to 1730 h (1530 h at weekends). There were three implementations periods: pre-implementation (2012); a developmental phase from January 2013 to August 2015; and full implementation from September 2015 to August 2016. The outcomes measured were disposition (discharged home, admitted or died); ED length of stay; hospital length of stay; all cause in-hospital mortality within 28 days; time to ED re-presentation up to 28 days post-discharge; in-hospital costs. The setting was a tertiary hospital ED, with 385 beds, in Queensland, Australia. Approximately 53,000 patients presented to the ED annually with 20% aged 70 years and older. All patients over the age 70 who presented to the ED between January 2012 and August 2016 (n = 44,983) were included in the trial. RESULTS: Older persons who presented to the ED when the GEDI team were working had increased likelihoods of discharge (Hazard ratio (HR) = 1.19; 95% CI: 1.13-1.24) and reduced ED length of stay (HR = 1.42; 95% CI: 1.33-1.52) compared with those who presented when GEDI were not working. There was no increase in the risk of mortality (HR = 1.01; 95% CI = 0.23-4.43) or risk of same cause re-presentation to 28 days (HR = 1.21; 95% CI: 0.99-1.49). The GEDI service resulted in average cost savings per ED presentation of $35 [95% CI, $21, $49] and savings of $1469 [95% CI, $1105, $1834] per hospital admission. CONCLUSIONS: Implementation of a nurse-led physician-championed model of ED care, focused on frail older adults, reduced ED length of stay, hospital admission and if admitted, hospital length of stay and cost, without increasing mortality or same cause re-presentation. These increases were sustained over time and after the initial implementation team had changed roles. TRIAL REGISTRATION: Australian Clinical Trials Registration Number ACTRN12615001157561 - retrospectively registered on 29/10/2015. Data were retrieved via retrospective access to clinical information systems. First data access was on 1/7/2015.

Nurse-led multidisciplinary initiatives to improve outcomes and reduce hospital admissions for older adults: The Care coordination through Emergency Department, Residential Aged Care and Primary Health Collaboration project.

OBJECTIVES: This article describes the Care coordination through Emergency Department, Residential Aged Care and Primary Health Collaboration (CEDRiC) project. METHODS: CEDRiC is designed to improve the health outcomes for older people with an acute illness. It attempts this via enhanced primary care in residential aged care facilities, focused and streamlined care in the emergency department and enhanced intersectoral communication and referral. RESULTS: Implementing this approach has the potential to decrease inappropriate hospital admissions while improving care for older people in residential aged care and community settings. CONCLUSION: This article discusses an innovative way of caring for older adults in an ageing population utilising the existing evidence. A formal evaluation is currently underway.

A structure, process and outcome evaluation of the Geriatric Emergency Department Intervention model of care: a study protocol.

BACKGROUND: Emergency departments are chaotic environments in which complex, frail older persons living in the community and residential aged care facilities are sometimes subjected to prolonged emergency department lengths of stay, excessive tests and iatrogenic complications. Given the ageing population, the importance of providing appropriate, quality health care in the emergency department for this cohort is paramount. One possible solution, a nurse-led, physician-championed, emergency department gerontological intervention team, which provides frontload assessment, early collateral communication and appropriate discharge planning, has been developed. The aim of this Geriatric Emergency Department Intervention is to maximise the quality of care for this vulnerable cohort in a cost effective manner. METHODS: The Geriatric Emergency Department Intervention research project consists of three interrelated studies within a program evaluation design. The research comprises of a structure, process and outcome framework to ascertain the overall utility of such a program. The first study is a pre-post comparison of the Geriatric Emergency Department Intervention in the emergency department, comparing the patient-level outcomes before and after service introduction using a quasi-experimental design with historical controls. The second study is a descriptive qualitative study of the structures and processes required for the operation of the Geriatric Emergency Department Intervention and clinician and patient satisfaction with service models. The third study is an economic evaluation of the Geriatric Emergency Department Intervention model of care. DISCUSSION: There is a paucity of evidence in the literature to support the implementation of nurse-led teams in emergency departments designed to target frail older persons living in the community and residential aged care facilities. This is despite the high economic and patient morbidity and mortality experienced in these vulnerable cohorts. This research project will provide guidance related to the optimal structures and processes required to implement the model of care and the associated cost related outcomes. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registration Number is 12615001157561 . Date of registration 29 October 2015.