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NPSTAT is reducing hospital transfers for long-term care residents in Mississauga Halton

by admin admin | Feb 01, 2009
An innovative new program in Mississauga Halton, Ontario, is reducing demand for hospital services, ambulances and acute care beds, while at the same time improving the quality of life of long-term care residents in the region. Nurse practitioners deliver a wide range of services in long-term care facilities and are averting hospital transfers as a result.

Key Messages

NPSTAT, an innovative nurse practitionerled outreach program, is having a positive impact on the quality of life of long-term care residents by avoiding unnecessary hospital visits.

The program is reducing demand for hospital services, ambulances, emergency services and acute care beds while simultaneously enhancing patient satisfaction.

The success of the NPSTAT pilot prompted the Ontario Ministry of Health and Longterm Care to allot $3.5 million to establish nurse-led long-term care outreach teams at each of the 14 LHINs across the province.

Transferring elderly long-term care residents to hospital can have negative effects on both the healthcare system and the seniors themselves. Unnecessary movement of seniors to hospitals means that much-needed beds are not available for other patients, and it can also put the seniors at risk of adverse events such as serious infections, drug reactions, and skin breakdown due to long waits on an emergency room gurney – all of which have the potential for serious or fatal complications. Residents can also suffer from “transfer distress,” characterized by disorientation, confusion, rapid deterioration in their condition, and comorbidity. Often, the residents never regain their previous levels of functioning and quality of life.

NPSTAT – nurse practitioners supporting teams averting transfers – was created to reduce these risks. An innovative nurse practitioner outreach program, NPSTAT is a collaborative effort of the Credit Valley Hospital and the Mississauga Halton Local Health Integration Network (LHIN).

Nurse practitioners provide same-day assessments of urgent problems in the LHIN’s long-term care homes. Working in collaboration with physicians and nursing staff, these nurse practitioners offer a range of services, including assessing acute and deteriorating chronic conditions, prescribing medications, ordering laboratory and diagnostic testing, implementing treatments such as intravenous antibiotics and suturing, counselling families, delivering palliative care, and certifying death.

The intervention of the nurse practitioners helps avoid unnecessary transfers to hospital. When residents do need to go to hospital, NPSTAT facilitates earlier discharges, thereby decreasing length of stays.

Planting a seed, growing an idea

Heather McGillis, director of patient care services at the Credit Valley Hospital, is still amazed at how a casual conversation in the elevator at work one day planted the seed of an idea that grew into NPSTAT. Her colleague, a geriatrician, told her that provincial funding would soon be available for creative, community-based initiatives to reduce emergency wait times.

At the time, Ms. McGillis was the chair of the Halton-Peel Emergency Services Network. She knew all too well that the increasing population in the region was leading to long wait times in the emergency departments, delays for emergency services, and higher demand for ambulances.

A significant contributing factor was the number of long-term care residents being sent to the emergency departments: more than 3,000 were sent to hospital in one year, and over half of them were admitted. Many of these residents were being sent to hospital because the physicians for the long-term care facilities were not available to do urgent assessments, or the facilities did not have the capacity to provide the level of care required by ailing residents. In addition, moving those patients from acute care back to long-term care was not always done expeditiously, resulting in fewer in-patient beds for new admissions to the hospitals and adding to the gridlock in the emergency departments.

Recognizing an opportunity, Ms. McGillis applied for and received provincial funding. The resulting pilot project, which ran from 2007 to 2009, is now the sustained NPSTAT program of the Mississauga Halton LHIN. With an annual budget of over $750,000, the program is funded under the provincial Aging at Home and Nurse-led Outreach envelopes.

Benefits in the ER and beyond

The satisfying part is that not only are we pioneering a new role, but we're pioneering it in a sector where it is so needed, in a sector that has truly embraced us - in a sector that appreciates us.

Although a formal evaluation of the program has yet to be completed, evidence to date shows NPSTAT is achieving its goal of reducing preventable emergency transfers. A statistical snapshot between April and July 2009 showed the program received 625 referrals, almost 70 percent of which were residents diagnosed with urgent or acute episodic illnesses. Of these cases, 88 percent avoided transfers to the emergency department. Dr. Jess Goodman, medical advisor to the NPSTAT steering committee and a physician at several long-term care homes, says the NPSTAT program fills a gap in service. “The program is structured to allow nurse practitioners sufficient time to treat residents,” he explains, “providing a clinical perspective that allows treatment of the acute issue and often providing a framework that improves ongoing care.”

The success of the NPSTAT pilot was the impetus for the May 2009 announcement by the Ontario Ministry of Health and Long-term Care for $3.5 million to establish nurse-led long-term-care outreach teams at each of the 14 LHINs across the province.

The LHIN’s long-term care home administrators, directors of care, and physicians see the positive difference NPSTAT is having on the lives of their residents – and, as an added bonus, on the skills of the staff. Linda Dacres, program co-ordinator and nurse practitioner, explains that part of NPSTAT’s work involves capacity-building among the nursing staff through the provision of expert knowledge and mentoring. The nurse practitioners also promote enhanced communication with family members. As an unexpected result, some families are changing the residents’ advance directives. “Once families realize there is an option, they are no longer instructing nurses to send the residents to the hospital,” explains NP Dacres. “They’re now asking for the nurse practitioner.”

Sharing lessons learned
The evolution of NPSTAT has been a journey, and NP Dacres is pleased to share the lessons learned along the way. She regularly presents the NPSTAT story at conferences and hopes to sow the seeds for similar programs across Canada and internationally.

A key to the successful implementation of NPSTAT was getting physician buy-in. The program invited physician “champions,” like Dr. Goodman, to be members of its steering committee. These doctors promoted the new nurse practitioner role among their colleagues and provided consultation on medical matters. They also approved medical directives required by the nurse practitioners when caring for long-term care residents. These directives were sent to the medical directors of the homes to ensure they were comfortable with them.

The Credit Valley Hospital and staff have been extremely supportive of NPSTAT from the program’s inception. The hospital has provided infrastructure, resources, and purchasing power not available through the long-term care homes: information technology, payroll, finance, human resources, library services, insurance coverage, purchasing, and pharmacy support.

What's next?

Now that NPSTAT has been implemented in all of the region’s long-term care homes, NP Dacres and Ms. McGillis are working to make it even better. They hope to obtain funding to extend the program’s hours to avert even more hospital transfers. They are also tracking a number of performance indicators and will be formally evaluating the program. There are also plans to study the parameters of the long-term-care outreach nurse practitioner role, as this is a new type of role for advanced practice nursing in Ontario.

“The satisfying part,” says NP Dacres, “is that not only are we pioneering a new role, but we’re pioneering it in a sector where it is so needed, in a sector that has truly embraced us – in a sector that appreciates us.”

Disclaimer:

Pass it on! is a publication of the Canadian Health Services Research Foundation (CHSRF). Funded through an agreement with the Government of Canada, CHSRF is an independent, not-for-profit corporation with a mandate to promote the use of evidence to strengthen the delivery of services that improve the health of Canadians. The views expressed herein do not necessarily represent the views of the Government of Canada. © CHSRF 2010