Riverbend Place Long-Term Care Home sends one patient per month to the emergency department (ED) on average, which is well below the provincial average of 16.
Health Quality Ontario had a chance to catch up with Dr. John Crosby, family physician and medical director of Riverbend Place to find out how they achieved their success.
Reducing avoidable ED transfers is often a big challenge for long-term care homes. What strategies do you use?
We use a number of strategies to reduce avoidable ED transfers.
Rounding three times per week
One of the biggest changes I’ve made to my practice is to make rounds three times per week instead of just once. This is because we’re seeing many more residents with complex health needs like mental health conditions, head injuries, neurological conditions, congenital conditions, and developmental delay. We’re also looking after patients with feeding tubes and on dialysis.
Hospitals are discharging residents sooner due to the pressures they face, which means our long-term care home is operating more and more like a hospital.
I make rounds on Mondays, Tuesdays and Thursdays at 9 a.m. so the residents and their families know I will be there for them. I am available all weekdays by cellphone, and we have a call system for the remaining times.
Rounding three times a week means I save time because I can diagnose diseases early when they are easier to treat. I also get fewer phone calls and faxes from nursing staff because they know I will be in regularly. Families and patients also feel much more confident with the extra care.
We have an excellent head nurse, Tanya Farrow, who is there when I round, which is key. I walk in at 9 a.m. and Tanya has a list of patients for me to see. We then chart, review lab work, imaging and other paperwork together. Tanya also makes rounds alone once a week.
Rounding more frequently has also helped us with other quality issues such as anti-psychotic use. I’m available more often to have conversations with family members about these important issues.
Educating residents and families
The next most important aspect is to get buy-in from residents and families about the benefits of care delivered in the home environment. Families need to be reminded that staff have developed a relationship with the resident and are confident they can provide effective care without causing the anxiety and stress that can result from an ED transfer.
We provide education upon admission and at family meetings, which we hold two months post-admittance and yearly. I attend all family meetings (for the first 10 minutes) to discuss medical issues and potential future transfers to the ED with the resident, family and power of attorney.
This type of education is worth the investment of time up front to avoid ED transfers in the long run.
The head nurse is also a consistent presence and talks to residents and families about ED transfers when warranted. She is the voice who helps educate residents and families of the pros and cons.
Building a task force
We put together a task force with a small group of people to determine the main causes of our ED transfers over the past year and what we could do about it. The task force includes me, a front-line nurse, a government funding representative, an ED representative, the CEO of the nursing home and an ambulance representative. Other representatives, such as from laboratory and X-ray can be pulled in when needed.
After looking at our data, we found that 70% of ED transfers were to get X-rays to determine possible hip fractures. We sent residents to the ED for same day X-rays, otherwise, we needed to wait one week to get X-rays.
Our LHIN decided to fund mobile X-rays in all nursing homes across Waterloo Wellington to avoid ED transfers based on the data we gathered.
The task force was helpful in tackling “low hanging fruit,” which ended up making a big difference.
Next year, we’ll reconvene and look at other ways we can improve quality. Our head nurse also studies all ED transfers, and reviews what the diagnoses were and how to avoid unnecessary trips.
As mentioned, we now offer same-day mobile X-rays on weekdays. Our head nurse has trained staff to administer I.V. therapy, which helps avoid ED transfers and gets residents back from hospital earlier.
What advice do you have for other long-term care homes?
Although there may be potential barriers to implementing some of the strategies mentioned above, I encourage all long-term care homes to identify their “low hanging fruit” and tackle just one issue at a time.
I also encourage long-term care homes to identify a champion that can take the lead on projects like this so that the work doesn’t fall through the cracks.
Do you work in long-term care?
Visit Quorum’s Indicators & Change Ideas page for more information on potentially avoidable emergency department visits.
You may also be interested in our quality improvement stories featuring the work of long-term care homes across Ontario.