The role of an advanced practice nurse (APN) in geriatric care at the emergency department

We refer to our recent article entitled 'Emergency Department Interventions for Frailty (EDIFY): Front-Door Geriatric Care Can Reduce Acute Admissions', which reported on the successful implementation of a program with the dual purpose of reducing the number of potentially avoidable acute admissions, and delivering frailty-centric care through interprofessional geriatric interventions (Chong et al., 2021). In this letter, we wish to highlight that the success of the program is a result of collaborative efforts from an interprofessional team of geriatric experts, one of which is the geriatric advanced practice nurse (APN). APNs are registered nurses who have acquired expert knowledge, complex decision-making skills and the relevant clinical competencies that result in the expansion of their roles beyond basic nursing care (Fougere et al., 2018). Within the scope of their practice, APNs with advanced skills can perform comprehensive clinical assessments, order and interpret investigations, diagnose medical conditions, develop care plans, and even prescribe appropriate medications. Additionally, APNs are responsible for promoting high quality care and leading training programs, which can potentially improve patient safety across the healthcare continuum (Fougere et al., 2018). Hence, an APN requires the amalgamation of good leadership, professional autonomy, advanced skills in their given specialty, together with collaboration and communication skills for effective teamwork with other healthcare professionals. There are rising demands to deliver safe and effective care to frail older persons with multidimensional and complex care needs, which commonly include medical, functional, psychological and social needs (Conroy & Parker, 2017; Foo et al., 2014). Furthermore, the added risk of functional dependency, morbidity and mortality among these individuals have been well established and efforts to mitigate these unwanted outcomes must be put in place. At present, numerous APN care models have been demonstrated to effectively reduce rehospitalization rates, lower healthcare costs, and improve patient satisfaction (Fougere et al., 2018). Hence, APNs are in an ideal position to contribute to better care for this vulnerable group across various clinical settings. In particular, geriatric APNs can attend to these individuals and provide targeted geriatric assessments, identify and manage frailty timely, and develop care plans to promote effective continuity of care in the community. In light of the global surge in the volume of frail older persons attending the emergency departments (ED), there is a call for EDs to be better equipped to cope with these rising demands. Whilst, there is limited data to support the role of APNs at the ED, it is increasingly evident that geriatric APNs play a crucial role in the delivery of frailty-centric care at the ED. Geriatric nurses at the ED have demonstrated favourable patient outcomes among frail older persons, which include reduced ED re-attendances and hospital admissions, reduced complications associated with ED presentations such as delirium, fall, functional decline and incontinence (Conroy & Parker, 2017), and reduced inappropriate hospitalizations in a cost-effective manner (Fougere et al., 2018). At our centre, the EDIFY program comprises of a team of geriatric experts including a geriatrician, senior resident, geriatric APN, pharmacist and physiotherapist. EDIFY significantly reduces potentially avoidable acute admissions without escalating the risk of rehospitalization, ED re-attendance or mortality, and with possible benefit in attenuating frailty progression (Chong et al., 2021). The program, which is led by a consultant geriatrician, empowers the APN to screen patients at the ED who meet criteria for EDIFY interventions. Once identified, the APN proceeds to review suitable patients by initiating the comprehensive geriatric assessments. If required, the APN can prescribe or adjust medications following a discussion with the EDIFY doctors. For patients who are deemed suitable for acute admission avoidance, the APN would communicate the plans with the patients or their caregiver and initiate appropriate plans for continuity of care on discharge. The APN also provides discharge advice, frailty education and counselling, and telephonic follow-up consultation, when indicated. Moreover, the APN has an established collaborative and consultative relationship with the ED staff and regularly provides expert advice and support to geriatric emergency medicine (GEM) nurses (Foo et al., 2014) and other healthcare staff at the ED (Table 1). In conclusion, hospitals must be prepared to embrace frailty-centric care models to provide optimal care to older persons presenting to the ED. The geriatric APN, along with collaborative efforts with other healthcare professionals, play an essential role in delivering timely geriatric care, and is potentially an important piece of the puzzle in realizing a frailty-ready ED. The authors express their gratitude to the staff of the Emergency Department of Tan Tock Seng Hospital for their unwavering support in the EDIFY program. In addition, the authors thank Dr. E. Chong, Ms S. Cheong, Ms B.Y. Ooi, Ms A. Ho, Dr. J.Q. Chia, Dr. C.L. Foo and Ms Y.C. Yeoh for playing a vital role in the success of the EDIFY program. No conflict of interest has been declared by the authors. Birong Zhu: conceptualization, drafting and writing; Selina Cheong: revision and editing; Edward Chong: conceptualization, critical revision and editing.