Doctor of Nursing Practice (DNP) Final Projects

Emergency department (ED) overcrowding is expected to increase at a rate of 1.9% yearly, leading to the inability to provide efficient and timely care, causing preventable medical errors and delays in time sensitive care. The Agency for Healthcare Research and Quality estimates that 21-33% of all ED visits are non-emergent and increased age correlates with increased use of Pre-hospital EMS systems and emergency rooms. This study aimed to determine if an advance practice nurse (APN) in an older adult pre-hospital setting could reduce the use of 911 for non-urgent calls and transports, using the para-medicine model of care. Available evidence demonstrated a decrease in non-urgent transports with potential for significant savings to the healthcare system.

This study was conducted in a community where 86.3% of residents are over the age of 65. The local fire department employed a full time APN who evaluated patients identified by EMS crews as at risk for repeat use of the 911 system. Following a 911 call and a referral by medics, the APN contacted patients to arrange a home visit. The purpose served to evaluate current health status, risks, and gaps in care. Interventions included assistance reducing safety concerns, assistance with coordination of care, and working with patient primary care providers to meet patient needs. Data collection included patient age, gender, number of 911 calls 30 days prior and 30 days post intervention, number of ambulance transports following intervention and PEI score after the initial APN visit.

Six patients (32%) accepted the intervention and 13 or (68%) refused the intervention, with a mean age of 86 years of age. Wilcoxin signed rank test indicates the number of pre-intervention 911 calls was statistically significantly higher than the number of post-intervention 911 calls. Z= -2.23, Asymp. Sig. (2 tailed) = 0.03. A Fisher’s exact test and Pearson’s Chai squared test did not demonstrate a statistical significance in the number of ambulance transports, which could be attributed to the low participation rate in the intervention (n=6). These results indicate that an APN in the pre-hospital setting can have an impact on use of 911 calls for non-urgent problems and. Furthermore, the ability to assist with care coordination and advocate for available services within the circle of the medical home closes gaps in care that are currently left unfilled.

Ineffective transitional care programs for ensuring the continuation of care from acute settings to the home settings post discharge can result in rehospitalization of elderly patients with chronic diseases. Usually, transitional care should be time-sensitive, patient-centered services intended to ensure continuity of care and an efficient transition between health care settings or home. A patient centered transitional care program was implemented at an outpatient primary care facility to reduce readmission rates. Institutional Review Board approval was obtained.

Twenty adult patients with chronic diseases discharged from an acute setting were identified. A follow up phone call and/or a home visit within 24-72 hours post discharge was employed. The Care Transitions Measure (CTM®) and Medication Discrepancy Tool (MDT®) were utilized to identify quality of care of transition and medication discrepancies. A chart audit collected data on the age of participant, diagnosis for initial hospitalization, CTM score, home visit, and ED visits or re-hospitalizations after 30 days of discharge. The outcome indicated that transitional care within primary care utilizing evidence-based practices is beneficial in reducing readmission rates. A logistic regression showed model significance, p = .002, suggesting that the CTM score was effective for both telephone support (TS) and home visit (HV).

A correlation analysis showed that as age of participants increased, the CTM score decreased, indicating that older adults required more support. A significance p <.001, of a proportional test indicated that readmission rates after the intervention was lower. It is evident that providing a timely and effective transitional care intervention in a primary care setting can reduce hospital readmissions, improve symptom management and quality of life of adult patients with chronic diseases.