How the Family and Community Nurse Can Foster the Reduction of Improper Emergency Room Admissions and Promote Chronic Patient Care: Single-Center Observational Study - Asst GOM Niguarda

Abstract

Background The incidence of improper access, with the consequent overcrowding of emergency room facilities, indirectly represents an indicator of evaluation of the local area's ability to take care of patients. In fact, overcrowding in the emergency room is often mainly attributable to patients requiring non-urgent or deferrable services, who access the emergency room due to the lack of hospital-territory integration, and for whom differential care could be envisaged in the setting of local care, as in the case of elderly patients suffering from chronic pathologies. The Family and Community Nurse (FaCN) is the professional figure of reference who ensures nursing care at different levels of complexity in collaboration with all the professionals present in the community in which he works, pursuing the interdisciplinary, health and social integration of services and professionals and placing the person at the center. Purpose From January 1st, 2023, a reporting process has been launched by the emergency room nursing staff for the chronic patient discharged to home and taken into care by the family and community nurse service. A retrospective single-center observational study was carried out on patients discharged from the Emergency Room of the ASST Grande Ospedale Metropolitano Niguarda. The data presented relates to the period 01.01.2023 - 30.09.2023. The purpose of the study is twofold: 1. Describe ways to ensure continuity of care between hospital and territory/primary care, identifying their level of complexity with the TRIAGE scale. 2. Identify the resources activated and interventions performed by the Territorial Team of Family and Community Nurses. Method Included in the study were chronic, home-discharged patients with chronic conditions who were domiciled or residing in the territory of afferent to ASST GOM Niguarda, referred by the nursing staff of the same emergency department and taken over by Family and Community Nurses (FaCNs). Exclusion Criteria affected chronic patients domiciled or residing in the territory of afferent to ASST Niguarda who refused to be taken in charge or admitted to hospital wards, intermediate care facilities, Health Care Residences for the Elderly. The triage scale is a first-level multidimensional assessment tool that aims at identifying complex social-health needs for the local area. It consists of eight items: morbidity, nutrition, alvus and diuresis, mobility, personal hygiene, mental status and behavior with whom he/she lives, and direct care. Four levels of severity are identified: absent or mild, moderate, severe, and very severe, with a score ranging from 0 to 2. The sum of the scores applied to the different domains constitutes the total score, which allows the complexity of patients to be stratified into three levels. The triage form is filled out by the Emergency Room nurse in the event of discharge of the patient and if the patient has a score between 3 and 10; the activation of the FaCN is envisaged through an email report made by the Caring Nurse to the Territorial FaCN service (pre-discharge phase). The FaCN takes charge of the patient and guarantees a series of interventions and care services in relation to the level of complexity of the needs expressed by the patient (post-discharge phase). Outcomes Patients discharged with chronic pathologies reported in the period indicated were 250, with an average age of 81.75 years (standard deviation 9.67). Most reports are included in the intermediate risk class between scores of 3 and 7, and the most represented age class is that of patients over 80 years old. In patients reported to the FaCN service, professionals reached the patient or his caregiver out for an initial approach, within 24 hours of discharge from the emergency room. The outcome of the reports made shows that in 48.8% of cases the FaCNs took steps to establish a connection between the FaCNs' service and the most competent territorial references closest to the patient and took care of them towards more appropriate services (home palliative care, mental health, etc.), while in 51.6% of cases the FaCN took charge of the patient directly, providing the appropriate care (medications, venous sampling, recording of vital parameters, health education interventions, therapeutic and engagement adherence, also through teleassistance). At the moment no other deaths have been recorded and in no case has the patient visited the Emergency Room again. Conclusion The activation of the FaCN for chronic patients discharged from the Emergency Room has made it possible to facilitate patient care, overcome the fragmentation of services, and guarantee continuity of care, both in cases in which the patient has been directly taken care of and assisted by the FaCNs, and in cases in which the patient has been directed/orientated towards other local services. Over time, it will be possible to reduce the volume of hospital care activities for fragile patients and inappropriate access to the Emergency Room, by strengthening the continuity of care, precisely guaranteed by the strategic value of the Family and Community Nurse.