Striking a Balance:Emergency Care for Long Term

Care Residents

NSGNA Annual DinnerWednesday May 13th, 2015

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

Scope of the Problem

• Grey Tsunami• ED overcrowding: waits• ED’s are not designed for older adults• Lack of community resources• Competing beliefs

What are we doing?

• Better Care Sooner• Care by Design• Expanded Role: DPN• Frailty Group

Case #1: Mr D

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

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

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

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

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

What could have been done differently?

Case #2: Mrs C

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

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

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

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

How was this different?

Discussion & Questions

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.