The WWLHIN (Waterloo Wellington Local Health Integration Network) NLOT (Nurse-Led Outreach Team) continues to work collaboratively with our Long-Term Care Homes (LTCHs) to reduce emergency department transfer rates to the lowest in the province.
Our NLOT team is comprised of 3 RNs and 1 NP; referred to as a “blended model”. The Nurse Consultants support all of the WWLHIN’s 36 LTCH’s through capacity building including education and coaching and mentoring which supports the LTCH in preventing ED transfers and allows for early repatriation back to LTCH, thus reducing hospital length of stay. The NP currently supports 2 LTCHs through the provision of acute & episodic care averting unnecessary ED transfers and hospital admissions.
One of the LTCHs supported is Sunnyside Home, Region of Waterloo, in Kitchener and the following identifies the planned change ideas related to effective transitions and continuing to maintain the current success of reductions in ED transfers:
Change Idea #1: Early referral to the Nurse Practitioner (NP) when residents have symptoms related to any change in medical condition, including but not limited to ambulatory care-sensitive conditions.
Method: Utilize NP protocol for referral (by RNs to NP).
Lessons Learned: Early identification in resident changes allows for more timely NP involvement, assessment and plan of care, which reduces ED transfers and potential hospital admissions.
Change Idea #2: Enhanced staff capacity to identify early changes in resident’s health condition via use of the SBAR (Situation, Background, Assessment, Recommendation) tool: to facilitate nursing assessment/communication of pertinent clinical assessment findings to MD/NP.
Method: Educate RNs about SBAR tool.
Lessons Learned: Current implementation is in progress, but utilization of the SBAR ensures there is effective communication around changes in resident’s health status or condition, which then prompts consultation and collaboration with the NP/MD for early assessment and interventions while preventing unnecessary and avoidable ED transfers.
Change Idea #3: Educate resident/family/ Substitute Decision Maker (SDM) re: goals of care and wishes including benefits to Emergency Department (ED) avoidance where appropriate.
Method: Communicate to resident/family/SDM via multiple mediums. Provide nurses with appropriate information to share with resident/family/SDM.
Lessons Learned: Ongoing measure, which allows for ongoing communication with the resident/family or SDM around resident goals of care and discussion about options for treatment that can occur in the LTCH and potentially avoids ED transfer.