Care Coordination in the Emergency Department: Improving Outcomes for Older Patients

Article excerpt

Abstract

This study aimed to evaluate the effectiveness of the care coordination (CC) program operating in the Emergency Department (ED) of The Northern Hospital in improving outcomes for older people and reducing ED admissions and re-presentations. This was achieved by comparing admissions from ED to wards pre and post commencement of the CC program, and measuring patient health-related quality of life pre and post CC intervention. Patient readmission rates and staff and patient satisfaction with the service were also investigated. Results indicate a statistically significant reduction in the proportion of patients admitted from the ED to a ward since the inception of the program, a significant difference in the mean-related quality of life scores before and after intervention by care coordination, and staff and patient satisfaction with the service. The readmission data collected in the present evaluation will serve as a baseline measure for future evaluations.

Aust Health Rev 2005: 29(1): 43-50

CONTINUING DEMANDS ON ACUTE CARE hospitals have resulted in an increased delay in admission of emergency patients to ward beds, blocking of emergency departments (EDs), and an increase in ambulance bypass.1 Older patients are often believed to cause "access block" due to the frequent need to admit them to hospital for reasons other than those that are purely medical. A shortage of available placements in aged care facilities and a lack of home support or other social issues are often the impetus for admission following a relatively minor injury or illness.2

In 1996, Street and colleagues3 reported on the complex issues surrounding presentation and discharge of older people from the hospital ED. They noted the difficulties of presentations where symptoms were sometimes non-specific, or where complex issues were compounded by disability and confusion. Patients who are not admitted as inpatients frequently suffer a deterioration in their condition, and up to 20% will re-present or be admitted within 1 month of discharge.4 Those who are discharged home from the ED often express apprehension about their ability to manage after discharge.3 In a study of ED usage by older Australians, Richardson reported that one of the strongest predictors of death or increased dependency within 3 months of discharge was found in presentations where social factors were of concern.5

The Northern Hospital (TNH) responded to an increased demand for service with the introduction of the care coordination (CC) program in the ED and in the inpatient wards in the year 2000. The hospital's ED is one of the busiest in Melbourne, and currently provides services to almost 45 000 patients annually.6

Service description

The CC program seeks to prevent not only unnecessary admissions from ED to hospital wards, but also inappropriate or unnecessary presentations and re-presentations to the ED, through the implementation of early interventions. In addition to preventative measures, CC aims to ensure the coordination and provision of services and programs for patients with complex care needs upon discharge from the ED back into the community. The program acts as a single point of contact for linking systems of social services, home and community services, health care and medical services and provides service to any potentially 'at risk' individual who may not otherwise be eligible for assistance under any other program.

CC is also a conduit between internal disciplines (for example between medical staff, allied health staff and social workers) and between internal and external services and stakeholders. The program aims to streamline patient movement through the hospital system and to speed up allocation of services, thereby enabling a smooth and swift discharge.

Cases to assess for intervention are identified by the ED CC team through external referral (Royal District Nursing Service (RDNS), general practitioners or community health services), internal referral from the ED medical/nursing team or from a review of triage presentation records. …