Advance Practice Nursing in the Pre-Hospital Setting

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.