Background: The important role of transitional care nurses (TCN) and social workers (SW) in the emergency department (ED) has been increasingly recognized, especially for geriatric patients who may be discharged after evaluation. Recent studies have demonstrated older ED patients receiving transitional care coordination are less likely to be admitted, thus reducing risks associated with hospitalizations and potentially lowering healthcare expenditures. It is unknown, however, if such programs impact performance metrics such as ED length of stay (LOS).
Methods: Prospective observational cohort study of geriatric ED patients (age ≥65) from 2013 - 2015 at Mount Sinai Medical Center (MSMC), Northwestern Memorial Hospital (NMH), and St. Joseph’s Regional Medical Center (SJRMC). The hospitals implemented geriatric ED programs to improve safer transitions at hospital discharge with multicomponent nursing and/or social work care coordination. Patients who received TCN or SW intervention while in the ED were matched to patients not receiving any transitions of care using entropy balance. Covariates included age, male sex, night or weekend ED visit, being seen in the dedicated geriatric ED, prior hospital discharge within 30 days, ESI, Charlson Comorbidity score, chief complaints (pain, falls, difficulty breathing, weakness, altered mental status, mental health), and Identification of Seniors at Risk score. Negative binomial regression models were used to estimate ED LOS in hours for each hospital.
Results: There were a total of 57,055 unique patients across all 3 sites. 11.89% of these were seen by TCN or SW (MSH 21,444, 13.38%; NMH 19,958, 12.63%; SJRMC 15,653, 8.85%). 40.85% were admitted to observation or inpatient status (MSH 45.28%, NMH 34.69%, SJRMC 42.64%). Using entropy balance, estimated ED LOS was longer in patients who received TCN or SW compared to patients not seen by a TCN or SW: 7.28 hours (95% CI, 6.73-7.84) longer at MSMC, 0.77 hours (95% CI, 0.61-0.93) longer at NMH, and 1.25 hours (95% CI, 1.02-1.48) longer at SJRMC.
Conclusion: TCN and SW interventions are associated with longer ED LOS for older ED patients that received transitions of care. For hospitals implementing transitional care coordination programs for older ED patients requiring comprehensive, multistep discharge planning, benchmarks for ED throughput may need to be reconsidered.