A Prospective, Randomised Controlled Trial of an Aged Care Nurse Intervention within the Emergency Department

Article excerpt

Abstract

The aim of this randomised controlled trial involving 224 elderly patients was to determine whether early geriatric assessment (in the form of an aged care nurse intervention based in the emergency department) reduced admission to the hospital, length of inpatient stay (LOS), or functional decline during the hospitalisation. Baseline geriatric assessments were recorded in the medical files of intervention patients (n=114). The nurse also liaised with the patients' carers and health care providers, organised referrals for out-of-hospital assessment and support services, and assisted in the care of those admitted as inpatients by documenting suggestions for assessment and referral. Assessment data from control patients (n=110) were withheld, and the nurse had no further involvement in their inpatient or outpatient care. One hundred and seventy-one patients (76%) were admitted to the hospital, for a median LOS of 10 days. The nurse successfully identified those needing admission (odds ratio [OR], 14.0; 95% confidence interval [Cl], 2.6-75.1). Thirty-nine of 160 inpatients with available data (24%) had a functional deterioration during the hospitalisation. The intervention had no significant effect on admission to the hospital (OR, 0.7; Cl, 0.3-1.7), LOS (hazard ratio, 1.1; Cl, 0.7-1.5) or functional decline during the hospitalisation (OR, 1.3; Cl, 0.5-3.3).

Aust Health Rev 2005: 29(1): 51-59

ELDERLY PERSONS VISIT the emergency department (ED) more often than younger persons.1 They often have serious complaints that limit function and restrict their ability to live independently. For many, hospitalisation results in functional decline despite cure or repair of the condition for which they were admitted.2,3 Functional status is a strong predictor of LOS, mortality, and nursing home placement.4,5 Early assessment of elderly patients can identify risk factors that contribute to hospital-acquired dependency.2,6

The best models of care for older persons visiting emergency departments are not known, and few randomised, controlled trials of interventions in the ED setting have been published. A two-stage intervention, comprising screening and a brief standardised nursing assessment and referral, reduced the rate of functional decline four months after the ED visit.7 The beneficial outcomes resulted primarily from early provision of home care services rather than early contact with the primary physician.8 Comprehensive geriatric assessment by an advanced practice nurse, with subsequent referral to community-based services, had no effect on overall service use (repeat ED visits, hospitalisations or nursing home admissions) at 30 and 120 days after the ED visit, though nursing home admissions were reduced at 30 days.9

In Australia, up to 68% of unselected elderly patients10 and 57% of those presenting after a fall11 are admitted to the hospital from the emergency department. Functional deterioration occurs early, with as many as 65% suffering a decline in mobility by day two of the hospitalisation.3 Although inpatient geriatric programs reduce LOS, mortality, morbidity, nursing home placements, and inappropriate medication use, and improve quality of life and functional status,12"15 many patients fail to improve. High-risk patients in particular may suffer irreversible decline before commencement of geriatric risk assessment and intervention programs.2,3 Despite this, and the potential for early intervention in the ED setting, there are no randomised studies of programs in this setting to reduce index admissions to the hospital, functional decline during the hospitalisation, or LOS. Our objective in this study was to evaluate the effect of a nurse experienced in multidimensional assessment and care of the elderly on these outcomes.

Methods

Hospital and ethics approval

The study was undertaken in 1996-97 in the ED of Liverpool Hospital, a busy, tertiary referral hospital in south-western Sydney, NSW, where an aged care nurse worked between the hours of 08:00 and 16:00, Monday to Friday. …