Advanced practice nursing and case management: An essential element in Emergency Services

Dear Editor,

We read with interest the article by Miguélez-Chamorro et al. published in the journal Enfermería Clínica, on the role of the case management nurse (CMN) as an essential figure in the care of complex chronic patients (CCP) in the health services. The review highlights the importance of the CMN in advanced practice nursing for healthcare action in the situation we are currently facing where the health services are being used by patients with multiple, chronic diseases.¹ We agree with the authors on the importance of the CMN in the care of vulnerable patients and in coordinating health teams given the demonstrated improvement with the actions of the CMN in the health-disease process and its associated determinants.²

We would like to add some thoughts based on our professional experience regarding the care of elderly patients with exacerbated chronic disease in hospital emergency departments (ED).

Caring for elderly patients in ED is becoming increasingly frequent, with their high levels of comorbidity, frailty and disability, which, given their limited physiological reserves and response capability to the various associated disease processes, place them more at risk of adverse outcomes.³ These patients might sometimes not meet the criteria of CCP, or might not have been identified as such earlier by primary care. It is known that the frequency of elderly patients in units linked to ED is very high, and that these patients are more likely to re-attend or be readmitted shortly after discharge than those who have been discharged from conventional hospital wards.⁴ It is essential to detect this profile of patients so that we can design a care plan and care transition, especially for patients who are going to be discharged directly from the emergency department.

Therefore, after demonstrating the effectiveness of CMN intervention for frail older adult patients who have been discharged from the short-stay units of the emergency departments, regardless of whether or not they have been identified as CCP beforehand, advance practice nursing intervention programmes are being gradually implemented in ED, particularly in the observation and short-stay units.⁵ In sum, systematic frailty screening is undertaken by the nurse in charge of those aged 75 and older who are to be discharged directly from these care units. During planning for discharge, a checklist is drawn up for patients who have been identified as CCP, and for frail older adult patients who have not been categorised as such beforehand, to establish whether it is necessary to activate the different hospital resources, according whether different domains are involved (cognitive, functional, social, nutritional and polypharmacy). In these cases, the competences of the CMN come into force in coordinating the intervention of the different professionals required, and ensuring continuity of care with primary care.

From our point of view, we believe that the experience has been very positive, since it detects elderly patients at high risk of adverse events, and therefore should be copied in other ED. On the other hand, we are aware that increasing the sensitivity of the case detection tool, and adapting the CMN to ED care model 24/7/365, will result in a greater need for resources. Therefore, more evidence is necessary on this intervention strategy. Pending such results, reporting that the role of the CMN in care areas such as units linked to the emergency departments, where the frequency of frail older adult patients is very high, is even more essential for the successful management of acute disease in these patients.