You work in a for-profit nursing home, with about 100 beds, on a 20-bed unit that is largely patients with Alzheimer’s disease. Your patient mix is predominantly Medicare and Medicaid patients. Your nursing home is part of a larger system that includes a major medical center, as well as VNA, outpatient dialysis, and a fully integrated network. Your nurse manager is getting feedback from the hospital that your nursing home is sending too many patients to the ED who really don’t need to go. How would you go about figuring out what could be done at the nursing home to prevent avoidable ED visits?

Step 1: Understand the Current Situation
Data Review

Collect data on all recent ED transfers: reasons, time of day, diagnoses, outcomes.

Identify how many visits resulted in hospital admission versus those discharged back to the nursing home.

Patterns & Trends

Look for common triggers (falls, infections, behavioral changes, dehydration, medication issues).

Note if certain shifts, staff, or units have higher transfer rates.

Step 2: Assess Internal Capabilities
Clinical Skills & Resources

Evaluate whether staff feel confident managing acute changes in Alzheimer’s patients (e.g., agitation, delirium, minor infections).

Review availability of on-site diagnostics (labs, portable x-ray, telemedicine consults).

Protocols & Guidelines

Check if standardized protocols exist for common issues (UTIs, dehydration, falls without injury).

Assess whether staff know when to call the physician or NP before sending a patient out.

Step 3: Engage Stakeholders
Staff Input

Hold focus groups with nurses and aides to understand why they choose ED transfer.

Identify perceived barriers (fear of liability, lack of physician availability, family pressure).

Family Education

Families often push for ED visits. Develop communication strategies to explain what can be safely managed in-house.

System Integration

Leverage the larger network (medical center, VNA, dialysis) to create rapid response pathways.

Step 4: Develop Interventions
Clinical Pathways

Create clear decision trees for common scenarios (e.g., fever, fall, agitation).

Implement “call provider first” rules before ED transfer.

Enhanced On-Site Care

Explore telehealth consults with hospital physicians.

Train staff in early recognition and management of acute changes.

Rapid Response Partnerships

Use VNA or hospital outreach teams for urgent but non-emergent issues.

Arrange for same-day outpatient visits instead of ED transfers.

Step 5: Measure & Adjust
Metrics

Track ED transfer rates monthly.

Monitor hospital feedback and patient outcomes.

Continuous Improvement

Adjust protocols based on what’s working.

Celebrate reductions in avoidable transfers to reinforce staff buy-in.

Example Practical Actions
Implement a “ED Transfer Checklist” requiring nurse manager or provider approval before sending a patient.

Train staff on Alzheimer’s-specific acute care management (e.g., behavioral de-escalation, hydration monitoring).

Establish a telemedicine link with the medical center for real-time physician input.

Create a family education packet explaining what conditions can be safely managed in the nursing home.

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