Nurse Led Symptom based Telephonic Triaging in Post Acute Care At Home Programme (PACH): Reduction in unnecessary Acute Hospital admissions

Abstract

Introduction: To meet the healthcare challenges of an aging population and the escalating health care cost, the role of the PACH nurses is vital, as they will follow up with discharged patients with complex medical conditions in their home settings and prevent potential complications. Schmitt,B. & Thompson, D.(2015) emphasized the importance in establishing symptom-based algorithms to promote a standardized approach to telephone triage which will also improve the consistency of the home care advice given by the nurses. Aim: To develop a set of standardized telephonic algorithms for the PACH nurses and also to measure the impact of using the established telephonic algorithms in reducing the incidence of admissions to the acute hospital. Methodology: An inter-professional (IP) team of four nurses and three physicians in the team identified about 22 common symptoms that they would often receive via telephone. Algorithms based on the respective symptoms were then formulated. They are then discussed, reviewed and enhanced during the Team’s in-services teaching. In Feb 2016, the PACH nurses were briefed to utilize the pilot algorithms. The pilot was commenced for a period of 6 months from April to September 2016, every Saturday. For each telephonic response received, the PACH nurse gathered information about the reason for the call and the symptoms experienced by patient. The nurse will then determine the need for home visit, follow up telephonic review, or advise for direct admission to Emergency Department. All the data collected were analyzed using Microsoft Excel software. Findings: A total of 45 telephonic consults were facilitated by the PACH nurses on Saturdays during the period of April 2016 to September 2016. In 57.7% of the telephonic consults, phone advice was given on seven most common symptoms, namely fever management, troubleshooting for tube feeding care, wound management , managing chesty cough, clarification on medication regime, bowel and urine related issues. 26.6% were scheduled for earlier PACH review, where patients were treated at home for pneumonia, urinary tract infection, fluid overload, and nursing related issues such as feeding tube care and urinary catheter care were being addressed at home. With phone advice and earlier PACH visits, we prevented re-attendance at the emergency department, and even admissions back to the hospital. This not only reduced healthcare cost for patients, it also prevented unnecessary utilization of hospital bed, thus resulting in further cost savings. The remaining of the 15.5% of the PACH patients were advised for readmissions as they required further acute medical intervention. The reasons for admissions were mainly pneumonia, sepsis and urinary tract infection. In these cases, telephonic triaging led to timely intervention for acute medical conditions, early treatment and thus kept potential complications at bay. Discussion: The symptom based algorithms do serve as comprehensive guide for the PACH nurses to provide consistent standardized assessment and care. However, thechallenge often faced by the nurses is the carer having deferring understanding on assessment from that of the nurses, which led to either delay in timely treatment, or inappropriate admissions to hospital. Moving forward, the utilization of telehealth to complement the current methodology in accurate and timely patient’s assessment may be explored. This would enable appropriate interventions. Conclusion: The symptom based telephonic algorithms are essential in assisting PACH nurses to standardize care plan and guiding them in their clinical decision making towards appropriate care management for their patients in the community. With the development of the telephonic algorithms, the incidence of unnecessary admissions to acute hospital has been reduced, bringing about a reduction in overall healthcare cost.