striking a balance: emergency care for long term care residents nsgna annual dinner wednesday may 13...
TRANSCRIPT
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Striking a Balance:Emergency Care for Long Term
Care Residents
NSGNA Annual DinnerWednesday May 13th, 2015
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Who are we?
Donna Naugler• Worked as LPN in LTC• RN Degree affiliated with
Queen’s University in Ontario
• Nursing Career:– Geriatric Assessment Unit– Internal Medicine – Emergency
• Discharge Planning Nurse
Nikki Kelly• RN from Dalhousie
University• Nursing Career:
– Neurosurgery– ICU in Georgia– Organ Donation Coordinator– Emergency
• MN-NP from Dalhousie• NP in the ED
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Scope of the Problem
• Grey Tsunami• ED overcrowding: waits• ED’s are not designed for older adults• Lack of community resources• Competing beliefs
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What are we doing?
• Better Care Sooner• Care by Design• Expanded Role: DPN• Frailty Group
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Case #1: Mr D
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Mr D
• 86 year old male lives in LTC• PMHx: – HTN, CAD, Vascular Dementia, Type II DM, Stroke
(right hemiplegia)• SHx: – Widowed x 5 years– 2 sons, live outside of NS– Requiring full care x 1.5 years
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Mr D Cont’d
• Decreased appetite for the past couple of days• Today while in the dining room, he became
weak & dizzy• Staff felt he ‘was not acting like himself’• 911 called• Paramedics Vitals:– Temp 38°, HR 98, RR 20, O2 Sat 92% on room air
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Mr D Cont’d
• Paramedics transported to QEII ED– Charge nurse/Charge Doctor not alerted about
patients arrival– No documentation accompanied patient
• Very busy day in the ED (overcapacity)• Patient has 5 hour wait in the hallway
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Mr D Cont’d
• Report given to ED staff could not clearly identify reasons for transport
• Mr D is drowsy but arousable, not oriented to person, place or time and has no voiced concerns
• ED Work-Up includes:– CT Head, Bloodwork, CXR, urine dip
• Diagnosis: pneumonia
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Mr D Cont’d
• The next day . . . (~16 hours after arrival):– Mr D is confused and agitated, required restraints
overnight & a sitter is booked for the day– DPN contacts LTC facility and gets pertinent
information faxed over• Patient has Advanced Directive:– No CPR, No Intubation– No hospital transport
• Mr D brought back home by ambulance with a prescription for antibiotics
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What could have been done differently?
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Case #2: Mrs C
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Mrs C
• 95 year old female in assisted living• PMHX: – HTN, OA, invasive bladder ca (newly found to be
metastic)• SHx:– Widowed x 20 years– 1 living daughter, 1 living sister
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Mrs C Cont’d
• Patient c/o 24 hour history of abdominal pain & vaginal bleeding
• Care Facility Staff:– Called on-call MD (who suggested ED)– Called 911– Called ED Charge Nurse– Copied Care Directive (full code) & other important
information
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Mrs C Cont’d
• Vital Signs:– Temp 36.4°, HR 118, RR 18, O2 Sats 98%
• Investigations:– Labs: HgB 82– Abdominal CT: invasive bladder ca with metastasis to
the colon• Consultation:– Urology– Internal Medicine– DPN
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Mrs C Cont’d
• Goals of care discussion with patient and family
• Decision to transition to comfort care• DPN arranged with urgent palliative care
consult to her in the community• Palliative care orders written and patient
transferred back to her home in LTC
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How was this different?
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Discussion & Questions
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References• Adams, J.G. & Gerson, L.W (2003). A new model for emergency care of geriatric patients. Academic
Emergency Medicine, 10(3): 271-274• deSouto Baretto, P. et.el. (2013). The nursing home effect: a case study of residents with potential
dementia and emergency department visits. Journal of the American Medical Directors Association, 14: 901-905.
• Gillespie, S.M. et.al. (2010). Health care providers’ opinions on communication between nursing homes and emergency departments. Journal of the American Medical Directors Association, 11: 204-210.
• Hwang, U. & Morrison, R.S. (2007). The geriatric emergency department. Journal of the American Geriatrics Society, 55(11): 1873-1876.
• Jablonski, R.A. et.al. (2007). Decisions about transfer from nursing home to emergency department. Journal of Nursing Scholarship, 39(3): 266-272.
• Latham, L.P. & Ackroyd-Stolarz (2014). Emergency department utilization by older adults: a descriptive study. Canadian Geriatrics Journal, 17(4): 118-125.
• McCloskey, R. & van den Hoonaard, D. (2007). Nursing home residents in emergency departments: a Foucauldian analysis. Journal of Advanced Nursing, 59(2): 186-194
• Terrell, K.M. & Miller, D.K. (2006). Challenges in transitional care between nursing homes and emergency departments. Journal of the American Medical Directors Association, 7: 499-505.
• Terrell, K.M. & Miller, D.K. (2011). Strategies to improve care transitions between nursing homes and emergency departments. Journal of the American Medical Directors Association, 12: 602-605.