Collaborative Working to Address Inappropriate ED Attendances by Nursing Home Residents

Abstract

Background: Increase in life expectancy in Ireland and social isolation has led to an increasing number of people living in residential care facilities (RCFs). Residents are frequently transferred to emergency departments (ED) for a variety of reasons. Studies found that up to 40% of these hospital admissions were deemed inappropriate. An inappropriate admission in previous studies has been defined as a situation in which care in lower cost settings would be as safe and less disruptive than care in higher cost hospital settings.

Methods: A review of a convenience sample of ED attendances to University Hospital Kerry (UHK) found that 50% were inappropriate. A SMART aim in a quality improvement project (QIP) is an aim which is Specific, Measurable, Achievable, Relevant and Time based. The SMART aim of this QIP was to reduce the number of persons residing in RCFs, being inappropriately referred to UHK, from 50% to 30% from March 2024 to May 2025.Quality improvement (QI) measures included the standardisation of terminology through the workings of the palliative frailty multidisciplinary team, development of a communication document on resuscitation status and treatment escalation preferences, and the implementation of an advanced nurse practitioner (ANP) palliative care service for RCFs supported by a palliative medicine physician. Education was integral in this QIP.

Results: QI measures resulted in a reduction in monthly ED attendances of RCF residents from a median of 82 to 50. Inappropriate attendances reduced from 50% to 31%. Stakeholders' feedback on the new service was overwhelmingly positive. The project resulted in financial savings for the health service.

Conclusion: Integration of the geriatric and palliative medicine services with staff of RCFs allowed for sharing of knowledge, standardisation of terminology and development of alternative models of care and pathways to access specialties. The introduction of a designated ANP palliative care service for RCFs has been essential in helping residents to receive the right care, in the right place, at the right time.

Keywords: Emergency department; Geriatrics; Nursing homes; Palliative Care; Quality improvement.

Figure 1. Run chart demonstrating the changes in ED attendances from residents of RCFs over the time period from January 2023 to April 2025. ANP, advanced nurse practitioner; ED, emergency department; RCFs, residential care facilities.

Figure 2. The run chart outlines the number of referrals of RCF residents to KSPCS for 11 months before and after the introduction of the ANP service. ANP, advanced nurse practitioner; KSPCS, Kerry Specialist Palliative Care Service; RCF, residential care facility.