Foyer St. Jacques Nursing Home is using a preventative approach to ALC by reducing the number residents who visit the emergency department (ED), thus avoiding the risk of residents experiencing lengthy hospital admissions, potentially losing their long-term care bed, and being designated ALC.
Alternate Level of Care (ALC) is a designation to identify patients in-hospital who no longer require acute care but are unable to transition to a more appropriate setting due to capacity issues, complex health and social needs and various other reasons. High ALC rates are a symptom of a system wide problem that requires all health sectors to work together.
To learn more about how they have significantly reduced ED visits, Health Quality Ontario had a chance to catch up with Shannon Watson, Assistant Administrator and Dietary Manager at Foyer St. Jacques Nursing Home.
Can you share what led to your significant improvement in reducing resident ED visits?
Falls resulting in injury have been our main reason for ED transfers. We have worked on developing a number of initiatives to help reduce falls, thus avoiding ED visits.
Bed rails free initiative
The Ministry of Health and Long-Term Care has required all long-term care homes to assess the safety of residents’ beds and the need for bed rails. Bed rails may cause injury to residents if they fall while trying to get over or around them. They may also cause injury if they become entrapped by them.
We purchased equipment to conduct our own assessments. Each resident’s bed, mattress and rails were individually assessed for safety and changes were made based on our findings.
Bed rails have now been removed from all our residents’ beds. Some residents use bed rails to manoeuvre in bed, so we installed a pole when needed to ensure residents can manoeuvre safely.
In addition to removing bed rails, we have purchased adjustable (“high-low”) hospital-style beds and thick absorption mats, which are placed on either side of the beds. These new beds and mats will further reduce the risk of injury from falls and entrapment.
Some residents, staff and family members thought it may jeopardize safety not to have bed rails, but with education, an adequate transition period and good data, we have been able to demonstrate the benefits of the new changes.
Beyond the bed rails free initiative, we conduct individual assessments to identify residents who are at high risk of falls. See the bed entrapment worksheet attached to this post. Processes are put in place to prevent falls and most importantly injuries from falls.
Photo includes a high-low bed and floor mats. The bed is shown in the lowest position and the mats are placed as they would be when a resident is sleeping.The mats fold up easily when not in use.
Bed alarm system
The Ministry of Health and Long-Term Care now provides broad funding per resident for fall prevention initiatives. We are using the funding this year to purchase a bed alarm system directly linked to the nursing bell system and pagers. The alarm alerts our staff when a resident is trying to get out of bed. The alarm system indicates in what room and bed the resident is located to ensure a quick response time from our staff. We are hoping that this new system will further reduce falls, injury from falls and ED visits.
Are there other reasons for ED visits among residents?
Yes. Our data shows that urinary tract infections (UTI) and dehydration are other common reasons for ED visits. We have created a more comprehensive hydration program and policy to help address these issues.
At point of care, our staff use a computerized system to document residents’ fluid intake. The system then generates a report that adds up residents’ fluid intake for the day. The night nurse compares residents’ daily intake to minimum fluid requirements. Residents who didn’t meet their requirements are encouraged to drink more.
Within 48 hours, if fluid intake is still not met, residents are provided with a labelled hydration snack (i.e. popsicles, Jello cup, a preferred beverage). The label indicates to staff that the resident is becoming at risk of dehydration and should use the hydration snack.
At 72 hours, we initiate a dehydration assessment and the nurse notifies the physician when there are signs of dehydration. IV therapy is not currently offered in our nursing home, but we are looking into this to avoid a hospital visit.
Do you have other initiatives to help reduce ED visits?
Yes. Champlain LHIN has developed an initiative where Community Paramedics are called to long-term care homes to provide additional services that might reduce transfers to the ED.
These services include Influenza Season Support, and offers services such as diagnosis, treatment and containment of the virus through swabs, phlebotomy or point of care blood test, IV therapy and administration of antiviral medication. Post flu season support is also provided through services such as IV therapy and fluid bolus for dehydration.
These services are in place however, we have not had to use the services yet. We look forward to evaluating the services once they are used to support our residents.
What is your advice for other organizations striving to reduce unnecessary ED visits?
I would recommend tracking the reasons for ED visits and developing initiatives to address your findings.
All our programs and initiatives have been driven by the data we collect. Good data is the key starting point to developing quality improvement initiatives.
One tool that has been very helpful is the bed entrapment kit through Cardinal Health. It guides you through the process of assessing residents’ beds to identify zones of risk. Using this tool has provided objective data that we’ve used to make our safety improvements.
Do you work on the ALC issue in your Long-Term Care Home? Write a comment or questions below.
You may be interested in our quality improvement stories featuring the work of long-term care homes across Ontario.