A Journal Article a Week (4/02/11): Effectiveness of gerontologically informed nursing assessment and referral interventions for older persons in the ED

Second in a series in response to Rob Fraser’s 2011 Nursing Research Challenge, which is to read a journal article a week, and report back to the world on what you learned. A tweet, even, will do. Excellent idea, and I strongly encourage all nurses out there on the Interwebs to participate by clicking here. I know a lot of nursing students and new grads read this blog — and in case you think your brain is all filled up, it’s a great way to keep on top of research. (I’m looking at you. And you too.)

APA citatation: Fealy, G., McCarron, M., O’Neill, D., McCallion, P., Clarke, M., Small, V., & … Cullen, A. (2009). Effectiveness of gerontologically informed nursing assessment and referral interventions for older persons attending the emergency department: systematic review. Journal of Advanced Nursing, 65(5), 934-945. Retrieved from EBSCOhost.

The Skinny: Do focussed gerontological nursing assessments and interventions make a difference in preventing admissions, decreasing ED use and improving the health of older people? Somewhat, counterintuitively, the results were mixed, but for a surprising reason. While increased nursing intervention leads to reduced functional decline and service use, new identification of additional health issues in this population makes full evaluation of efficacy difficult.

Money quotes:

“While assessment and referral interventions may reduce service use, somewhat paradoxically, such interventions frequently highlight health problems that may increases service use . . . Forexample, Caplan et al. (2004) reported that, on average, 1.65 new problems were identified in the intervention group,resulting in increased general practitioner (GP) and outpatient visits and some return visits to the ED . . . It may be that the overall economic benefits of such interventions are questionable . . . [W]hen  models are applied, it appears that the financial benefits of such interventions are negligible . . .”

“Bridges et al. (1999) question the real value of interventions of this type, as most focus on supplementing what EDs currently offer, rather than fundamentally re-thinking ED service provision for older people. As self-referral is the most common source of referral to the ED (Basic &Conforti 2003) and many older people present with problems requiring urgent intervention (Eagle et al. 1993), ED-based interventions aimed at reducing service use may have little overall impact, as healthcare professionals may ultimately have little real influence on decision to attend the ED.”

“The evidence concerning the effectiveness of gerontologically informed nursing assessment and referral interventions for older ED attendees indicates benefits in terms of reduced service use and reduced functional decline. However, there is also evidence of ineffectiveness in predicted patient and/orhealth systems outcome . . .”

New Insight: Emergency departments are ill-equipped to deal with the complex health/social needs of the elderly, and programs like GEM (geriatric emergency management) nurses may not be as effective as we might think. It’s the old complexity versus acuity problem. EDs do acuity well. Complexity? Not so much.

Why You Should Care: Provision of emergency services to the elderly is an issue that is becoming acute as the population ages. Designing models and processes to care for geriatric patients effectively, in mitigating service and re-visits, preventing functional decline and maintaining over-all health is going to be a critically important issue in which nursing input will be vital.

Next week: “Mentoring in Emergency Care: Growing Our Own.”

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