NPSTAT – Nurse Practitioners tackle ED transfers

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It’s a heart-wrenching scene. An elderly patient, disoriented and in pain, lying in wait on an uncomfortable stretcher in an emergency department. It’s a picture any emergency department caregiver hopes to avoid. A new initiative at the Credit Valley Hospital in Mississauga is painting a picture of a different sort, through a collaborative effort with its local nursing homes. It’s called NPSTAT – a nurse-led long term care outreach initiative.

In the Mississauga Halton region, there are approximately 152,000 adults over the age of 60. Over the next ten years, this number is projected to increase by over 50 per cent to 231,000 adults, making up 18 per cent of the total local population. These statistics indicate that the Mississauga Halton Local Health Integration Network (MH LHIN) has the second-highest projected growth rate in the fourteen LHINs across the province of Ontario.

Persons over the age of 65 presently account for approximately 40 per cent of all hospital admissions in the MH LHIN and, due to the complex needs and multiple diagnoses of seniors, they stay longer and require more resources than younger patients. While most seniors are in good health and able to live independently, today 3.6 per cent of seniors in the MH LHIN reside in Long-Term Care (LTC) facilities. Survey results from a November 2007 – April 2008 study indicate that residents from LTC homes had a very high rate (63 per cent) of in-patient admissions to hospitals. Studies also indicate that hospitalization can often cause functional decline in many LTC facility residents.

In addition to the potential for health decline in elderly patients awaiting treatment in a hospital, there are several other factors contributing to frustrations and problems in Mississauga Halton hospitals: the majority of LTC residents are transported to and from the hospital by ambulance, reducing access to emergency services for other patients requiring emergency transfer, and congestion caused by the wait for in-patient beds can also contribute to further delays in the emergency department. The risk for the elderly patient, especially when these factors are compounded, is that their normal levels of functioning may be seriously reduced, thus increasing the risk of further health decline and longer stays in hospital.

In anticipation of the dramatic increase in the elderly population of Mississauga Halton and with support from the Province of Ontario’s Emergency Department (ED) Wait-Time Strategy and the Aging at Home Strategy, the MH LHIN has developed NPSTAT (Nurse Practitioners Supporting Teams Averting Transfers). NPSTAT provides nurse practitioner services to LTC facilities in the MH LHIN in an effort to decrease the rate of transfer to local hospital emergency departments by addressing acute and episodic illness in LTC residents through nurse practitioner assessment, diagnosis and therapy.

While it is a MH LHIN initiative, NPSTAT has been managed primarily through The Credit Valley Hospital. NPSTAT program director Heather McGillis has quarterbacked the project since its inception and is delighted to see the program prosper. “Overseeing this program has been an interesting and exciting challenge and I have learned much about how integration can benefit all parties; in this case the frail elderly residents of LTCs and the reduction of some of the pressure in our busy emergency departments. It is a real pleasure to see a successful pilot project reach sustainability.”

The initial pilot project ran from April 2007 to April 2008 and by January 2008, the project included four LTC homes in the Central West LHIN as well as eight LTC homes in MH LHIN. The results were impressive: 42 per cent of LTC patients seen were directly diverted from the ED, 34 per cent were less-urgent cases, but care was instituted that potentially prevented a resulting transfer to the ED at a later time and 24 per cent were non-urgent but provided an opportunity for education and teaching.

By September 2008, sustainable funding through the Aging at Home initiative divided the pilot along LHIN lines. The recent addition of Nurse-Led Outreach Team dollars will expand the MH LHIN program. NPSTAT is currently operational in nearly 50 per cent of the MH LHIN long term care facilities but will be expanding to cover all 27 LTC homes in the MH LHIN, hopefully by the end of summer 2009. “I feel very strongly that the NPSTAT team is filling a crucial role in providing an essential service to long term care facilities,” says Dr. Jess Goodman, medical advisor to the NPSTAT steering committee. “Physicians aren’t always able to provide the urgent assessments that the NPSTAT team is able to carry out.”

Susan Ash is director of care at Sheridan Villa Long Term Care Centre, a residence in the process of implementing the NPSTAT program. “The nurse practitioner program is a key component in the collaborative partnership between acute care and community, which ultimately leads to best possible outcomes for our seniors,” comments Ash. “Residents who thrive in familiar surroundings will often become fearful and confused by transfers out to an emergency department. Outcomes are much more positive when residents and their families are able to remain in the comfort of their familiar environment to receive services that may have otherwise been given in hospital.”

The collaboration between the MH LHIN, physicians, the LTC facilities, the CCAC (Community Care Access Centre) and the nurse practitioners is integral to the success of the NPSTAT vision. While decreasing ED wait times and the number of transfers from LTC homes to hospitals are NPSTAT’s primary objectives, additional benefits seen in the program include enhanced development and sharing of best practices, process improvement and standards among all parties. Dr. Goodman, himself a physician at multiple LTCs in the MH LHIN, is thrilled with NPSTAT’s contribution to his facilities. “NPSTAT professionals are able to… resolve many medical issues that may have otherwise resulted in transfer to a hospital emergency department. The [NPSTAT] teams have assisted in improving the health of patients in long-term care facilities and in decreasing transfers in a very significant way.”

Adapted from earlier pilots in Hamilton and Niagara region, the benefits of NPSTAT in the MH LHIN are now well-recognized and similar teams are being developed across the various LHINs. The unique medical management of elderly patients is an opportunity for NPSTAT to support, enhance and collaborate with the health-care teams at LTC homes for the best possible patient care. The increase in the senior population over the next decade is staggering. NPSTAT will help to alleviate ED visits, length of stay for patients transferred to the ED, reduce admissions for conditions that may be treated out of hospital and reduce the overall length of inpatient stay in an acute-care hospital in LTC residents. Now that’s a much prettier picture!