Educating Nursing Home

Nurses on Efficient Use of the

Emergency Department

N U R S E E D U C A T O R

Authors: Sandra Mercer, RN, CEN, and Sherry Robinson, PhD,

RNCS, Springfield, Ill

Section Editor: Laura T. Gantt, RN, PhD, CEN, CAN, BC

Sandra Mercer is Clinical Nurse III, Emergency Department, MemorialMedical Center, Springfield, Ill.

Sherry Robinson is Gerontological Clinical Nurse Specialist, SIU Schoolof Medicine, Department of Medicine, Springfield, Ill.

For correspondence, write: Sherry Robinson, PhD, RNCS, SIU Schoolof Medicine, Department of Medicine, PO Box 19636, Springfield, IL62794-9636; E-mail: srobinson3@siumed.edu.

J Emerg Nurs 2008;34:74-6.

Available online 3 December 2007.

0099-1767/$34.00

Copyright n 2008 by the Emergency Nurses Association.

doi: 10.1016/j.jen.2007.05.002

74

emorial Medical Center in Springfield, Illi-

M nois, is a ‘‘Nurses Improving Care to Health

Systems Elders’’ (NICHE) Hospital. One of

the goals of the NICHE Committee is to improve care

to elders across all services. The emergency nurse, who

is a member of the NICHE Committee, queried other

emergency nurses to identify the most pressing issues they

faced in caring for elders. Repeatedly, the response was

related to patients who were admitted from nursing homes.

Nurses believed elders residing in nursing homes experi-

enced excessive lengths of stay in the emergency department.

In addition to dealing with the elder’s urgent need, the

longer length of stay necessitated careful attention to basic

care issues of toileting, nutrition, pressure ulcer preven-

tion, comfort, and rest. The nurses did not believe they

had enough resources to deliver all the care needed. The

nurses believed that some long stays were related to finding

return transportation to the nursing home.

The gerontological clinical nurse specialist (GCNS),

who served the hospital, also made regular rounds at local

nursing homes. She was hearing similar complaints from

nurses at the other end of the spectrum. Nursing home

nurses could not understand why their patients had such

long waits in the emergency department.

Examining the Problem

To examine the issue further, the emergency nurse and

the GCNS examined records of 50 patients who arrived

from nursing homes. The study was granted exemption

by the Springfield Committee for Research Involving

Human Subjects. The average length of stay was 5 hours

and 50 minutes, with the longest stay being 17 hours and

JOURNAL OF EMERGENCY NURSING 34:1 February 2008

N U R S E E D U C A T O R / M e r c e r a n d R o b i n s o n

19 minutes. Twenty of the patients arrived in the emer-

gency department between 4 PM and 10 PM. In our com-

munity, medivans do not operate after 5 PM. Only

ambulance service is available, but a person must meet

certain criteria for the ambulance transport to be covered

by Medicare. Five elders who were ready to return to the

nursing home in the evening could not return because the

discharge criteria did not meet Medicare standards for an

ambulance transfer. They had to spend the night in the

emergency department and return to the nursing home via

medivan the next morning.

An additional problem was identified with the record

review. Of the 50 records examined, 26 of the elders came

through the emergency department because the physician

had ordered blood transfusions, replacement of a G-tube, a

radiograph, or placement of a peripherally inserted central

catheter (PICC) line. All of these procedures are provided

by infusion services, special procedures, radiology, or inter-

ventional radiology. At our hospital, these services are

staffed from 8:00 AM to 4:30 PM. Consequently, the elders

who came through the emergency department had to wait

until hours of operation or until they could be worked into

the special department’s schedule.

Developing the Educational Program

Questioning of nursing home nurses by the GCNS

revealed that many nurses were unaware of the Medicare

regulations for ambulance transfer. Additionally, they

explained that it often was late in the afternoon when

they received calls from physicians’ offices giving the orders

for the various procedures. They thought they were acting

appropriately by sending patients through the emergency

department for blood transfusions, radiographs, G-tube

placements, and PICC line placement.

To remedy the situation, the emergency nurse devel-

oped an education program for nursing home nurses.

All of the special services departments were contacted to

determine the most common procedures utilized by elders

from nursing homes. A short in-service session and a

laminated card with telephone numbers for (1) infusions

services, where blood transfusions could be arranged, (2)

special procedures, where scopes could be arranged, and

(3) radiology, where feeding tubes and PICC lines could be

February 2008 34:1

scheduled (Figure 1), were developed. All of these services

could be arranged without sending patients through the

emergency department. An appointment could be made and

elders would not experience excessive waits. At the top of

the card, the emergency charge nurse’s number was listed,

where nursing home nurses could call with any questions.

Additionally, a list of transportation services was in-

cluded. The emergency nurse was able to locate one ambu-

lance service that would transport persons with nonemergent

problems for a private fee.

The emergency nurse then visited 8 nursing homes in

Springfield, accompanied by a representative of one of

the ambulance services. During a brief in-service session,

the emergency nurse explained that if the condition of the

elder would not be compromised by waiting until morn-

ing, the services would be much more efficient. Elders

would not have to experience the long waits. The elder also

would be much less stressed and experience less discomfort.

The representative of the ambulance service explained the

criteria for returning patients to the nursing home via am-

bulance. Nursing home staff members were encouraged to

ask the physician if the patient could be transported the

next morning after an appointment was set with the special

services. Copies of the card were left with the directors of

nursing to distribute to the nursing units.

To reinforce the use of the cards, the GCNS carried

additional cards. As she made rounds at the nursing homes,

she checked with each nurses’ station to see if they had

received the card. If not, one was displayed in an

appropriate place.

The Outcomes

The emergency nurse was well received by the nursing

homes. The nurses appreciated that the emergency depart-

ment was reaching out to them and had prepared some-

thing for them to facilitate care for their elders. The

emergency nurse approached them with respect and in a

positive manner with no intent to criticize them, but with a

mutual goal of providing better care for their elders.

To our knowledge, within the past month there have

been no admissions through the emergency department

when appointments should have been made in the special

JOURNAL OF EMERGENCY NURSING 75

FIGURE 1

Contact numbers for hospital services frequently used by

nursing homes.

N U R S E E D U C A T O R / M e r c e r a n d R o b i n s o n

76 J

areas. Occasionally, a transportation problem still occurs,

but transportation problems are not occurring as often.

Probably the best outcome is the relationship that is

developing between the nursing homes and the emer-

gency department. Nursing home nurses are encouraged to

phone the charge nurse in the emergency department with

any questions. Nursing home nurses are taking advantage

of this opportunity.

In conclusion, long stays in the emergency department

are difficult for elders. The literature documents that as the

wait becomes longer, nurses must focus on issues of basic

care, comfort, toileting, nutrition, position change, and

skin care along with providing care for the acute illness or

injury. In an environment where nurses are providing

expert emergency care in critical situations, dealing with

these basic care issues becomes a challenge.1-5 With aging

of the population, emergency nurses must continue to

focus on improving care provided to elders in the emergency

department. Educating our nursing home peers about effi-

cient use of the emergency department is one way to improve

emergency care for a subgroup of the geriatric population,

elders arriving from nursing homes.

REFERENCES

1. Nerney MP, Chin MH, Jin L, Karrison TG, Mullikin R, MillerA, et al. Factors associated with older patients’ satisfaction withcare in an inner-city emergency department. Ann Emerg Med2001;38:140-5.

2. Grief CL. Patterns of ED use and perceptions of the elderlyregarding their emergency care: a synthesis of recent research.J Emerg Nurs 2003;29:122-6.

3. Watson WT, Marshall ES, Fosbinder D. Elderly patients’perceptions of care in the emergency department. J Emerg Nurs1999;25:88-92.

4. Kihlgren AL, Nilsson M, Skovdahl K, Palmblad B, Wimo A.Older patients awaiting emergency department treatment. ScandJ Caring Sci 2004;18:169-76.

5. Gokula R, Hickner J, Smith M. Inappropriate use of urinarycatheter in elderly patients in a midwestern community teachinghospital. Am J Infect Control 2004;32:196-200.

OURNAL OF EMERGENCY NURSING 34:1 February 2008