Across the United States and around the globe, emergency departments (EDs) are frequently bursting at the seams – corridors crowded with sick people waiting for hours on stretchers or languishing on uncomfortable chairs. Such images do not inspire confidence in the health care system.
One of the populations that contribute most often to ED overcrowding is elderly patients who are transferred from nursing homes and other long-term care facilities. “When these patients are seen in an ED, they have longer stays, undergo more comprehensive testing and consume a larger amount of resources (such as staff time) than other adults,” observed Amy Thomas, a student in The University of Tulsa’s doctor of nursing practice (DNP) program (family nurse practitioner stream) who this fall entered her third and final year of studies.
Thomas explained that the frequent lack of communication and information about a resident’s health status and history upon transfer contribute to the problem. “Given that older Americans are expected to account for approximately 20% of the nation’s population by 2030 and that patients age 85 and up comprise almost 22% of ED visits, it’s vital we tackle this issue now,” she said.
Better information, better care
For her DNP research project, Thomas plans to investigate bridging this gap by employing a standardized report form for patients transferred from nursing homes to emergency rooms. Thomas’ decision to focus on this specific population was driven by the fact that each year 75% of nursing home residents are transferred to an ED.
According to Thomas, however, “there is not a standard process or form that health care workers can use to relay critical health information for these patients. Three of the main types of information that would be useful for ED staff to have are patients’ medication lists, baseline mental status and details about their advanced directives.” Research shows that information gaps associated with such transfers are linked to increased length of stay, higher health care costs and more adverse events.
Health-system scholars have identified the potential value of standardized report forms for nursing-home-to-ED transfers, and the use of such tools for a variety of patient transfers has been tried in other jurisdictions. New Jersey, for instance, has had a statewide policy that mandates the use of a universal transfer form when moving individuals from one health care facility to another. “This is an example of a successful quality improvement strategy that has resulted in good outcomes for a vulnerable population,” Thomas noted. Closer to home, she is drawing on the lessons learned from a similar initiative successfully carried out by the Community Care Transitions Team in Bartlesville, Oklahoma, and she plans to adapt the validated form used by that group.
Project method and design
Thomas has planned her three-phase research project as a collaborative undertaking involving the 12-bed emergency room at Tulsa’s Saint Francis Hospital South (where she works as a critical care nurse), two regional nursing homes and emergency medical services (EMS) staff. The first phase will entail Thomas educating staff at the nursing homes, EMS line and the ED on the purpose and use of the standardized form.
“I was very excited to hear about Amy’s project,” said Dee Crookham, the clinical manager of the Saint Francis Hospital South ED. “It will give us a standardized document to use for obtaining the information we need to care for patients coming to us for care from nursing homes. We receive such patients frequently, but we are rarely called with a report prior to their arrival. Often, we receive minimal information on such things as medications (including last-dose administration times), pertinent medical history, family contacts and do-not-resuscitate status. Having a standardized way to obtain such details that are used by all facilities sending patients to the ED would make the transition of care flow much more smoothly,” she said.
“I am deeply thankful for the support of all my community partners,” said Thomas. “I am particularly grateful to Dee Crookham. She was super excited when I first mentioned it to her, and she is as invested in the success of my project as I am.”
Phase two of Thomas’ project will last three months and take place in spring 2020. It will entail using the forms for patient transfers from nursing homes to the ED. Patients’ length of stay (LOS) – hours and minutes from the time of registration to either admission or discharge – will be calculated using data collected in their EPIC electronic medical records. “Patients without transfer forms will be the control group that will enable direct LOS comparison,” she explained. The project’s final phase will see Thomas analyzing the data and disseminating results.
Effecting system change
“Amy’s project has the potential to make a positive impact on patient care by reducing medical errors and promoting ethical decision-making by health care providers,” noted Sheryl Stansifer, the director of TU’s School of Nursing. In fact, Crookham has volunteered this initiative to be considered a “change project” for the Saint Francis Hospital South ED.
“A change project is a systematic endeavor that has the potential to modify practice not just for a chosen facility but for an entire health system,” Thomas noted. Once she has had an opportunity to evaluate her project and evaluate the results, Thomas’ work will be assessed as a system-wide pilot project to bring about beneficial practice change that has the potential to affect thousands of lives. “My goal as an ED nurse and future nurse practitioner is always to provide more efficient and timely care, and I am hopeful this project will help to bring that about. I can’t wait to get started.”
Becoming a nurse practitioner through TU’s doctor of nursing practice program is a three-year journey toward health care excellence. If you hold a BSN and would like to advance your knowledge and career as a nurse practitioner, TU offers two pathways: family nurse practitioner and adult-gerontology acute care nurse practitioner. There’s also a post-master’s pathway for advanced practice nurses.