ORLANDO (EGMN) – A new program deploying emergency department nurses to consult on the acute care concerns of long-term care nurses kept many nursing home residents from being transferred unnecessarily to a hospital in Toronto.
During a 1-year pilot study of the now-ongoing program, nursing home–requested consultations prevented otherwise automatic transfers of 497 residents to the emergency department (ED), Dr. Samir K. Sinha said at the annual meeting of the American Geriatrics Society. Although the nurses determined that 109 of these patients (22%) should in fact be transferred to the ED, 388 (78%) didn’t require transfers and instead received treatment in a nursing home.
Thus the Mobile Emergency Nursing program at the University Health Network in Toronto proved cost effective, said Dr. Sinha.
Although it is a Canadian program, “health care reform ... could make this a more attractive model in the United States,” said Dr. Sinha of the division of geriatric medicine and gerontology at Johns Hopkins University, Baltimore.
“Our current reality is that hospitalization of nursing home residents can cause discomfort for the residents, morbidity due to iatrogenic events, and excess health care costs,” Dr. Sinha said.
Nursing home physicians supervise the program. In the pilot study, three registered nurses and one nurse practitioner with acute care experience worked out of an ED at an urban teaching hospital in Toronto. The nurses provided support from 9 a.m. to 7 p.m. daily to nursing staff at 15 local long-term care nursing homes with a total of 3,313 residents. The program is “unique in its focus on peer-to-peer consultation,” Dr. Sinha said.
Hydration, pain, dyspnea, infection, and problems with enteral feeding tubes were the top five reasons for consultations.
In addition to the acute care consultations, which took place from October 2008 to October 2009, the ED nurses were consulted another 120 times for nonacute care concerns, including patient management advice, Dr. Sinha said. The mobile nurses also performed 534 follow-up visits during the study.
The researchers’ cost analysis demonstrated overall savings with the program, despite some higher clinical costs. For example, a clinical consultation by a mobile nurse typically cost $410, vs. $324 for an ED patient visit. The program’s savings came from significantly lower transportation costs – an average $53 for an ED nurse to go to a nursing home vs. $265 to transport a patient to the ED. Therefore, total costs were $463 on average for a nurse consultation versus $589 for an ED visit.
“Our clinical costs were higher, mostly due to the salaries of those four nurses,” Dr. Sinha said. “We still proved ourselves to be [21%] less expensive ... than an ED visit.”
He listed as the four main components of the pilot program:
–Prevention. Nurses rounded in the nursing home to build familiarity and reassure nursing home nurses that they can be contacted when needed, Dr. Sinha said.
–Avoidance. The mobile nurses were available for assessments and coaching by telephone and for management of acute conditions during site visits. “Emergency situations went directly to 911,” said Dr. Sinha.
–Rapid ED-staff engagement. When the nurses recognized that a patient needed to go to the hospital, they could enable rapid transfer, intervention, and discharge. Dr. Sinha said, “They call ahead and say: ‘This is what the issue is going to be.’ ”
–Follow-up. The mobile nurses consulted on hospitalized patients daily until discharge, with another follow-up within 24 hours at the nursing home.
The model of care has been expanded to 34 nursing homes in central Toronto, Dr. Sinha said. “The program is now running full time with full government support.” The study was supported by a Nursing Secretariat grant from the government of Ontario.
Dr. Sinha said he had no relevant financial disclosures.