When an 82-year-old woman suffered a mechanical fall that landed her in the emergency department with a pubic rami fracture, hospital staff had a choice. They could either admit her to the hospital or come up with another plan to get her out of the ED.
Michelle Galles, DNP, APRN, AGACNP-BC, shared three case studies that illustrate the important role APRNs play in patient care and clinical leadership.
“We know these are not surgical injuries,” said Michelle Galles, DNP, APRN, AGACNP-BC, an acute care nurse practitioner at Round Rock Medical Center in Texas and assistant professor at Texas State University. “So, what is the benefit of admitting you to the hospital?”
Although a hospital admission would provide pain control and moderate amounts of rehab, the “three midnight rule” would require a longer-than-necessary inpatient stay in order to transfer the patient to a skilled nursing facility. That, in turn, would not only inflate her length of stay but introduce risks like hospital-acquired infections and deconditioning.
As an APRN, though, Galles knew about a third option: A local “loophole” allowing certain Medicare patients to be fast-tracked to an inpatient rehab facility directly from the ED.
“Why not fast-track them out and get them the care they need versus leaving them in the hospital?” Galles said. While rules vary by state, “maybe it’s worth reaching out and saying, ‘Hey, do we have any other options?’”
Calming the Chaos
This patient’s story was one of three real-life case studies Galles shared with attendees during the Emergency Nursing 2025 session “My Circus, My Tightrope Walkers: Staying Balanced When Dealing with Systems Chaos in the ED.”
The session explored the role of APRNs in managing patient care within hospital settings and the invaluable resources they are in providing clinical leadership, patient advocacy and specialized care delivery to improve patient outcomes, optimize health care resources and foster interprofessional collaboration.
Session attendee Laura Gallagher, MSN, APRN, ACNS-BC, an education clinical nurse specialist at the Community Training Center at the Medical University of South Carolina, said the key element of the session that resonated with her was “the fact that hospitals are dangerous places.”
“If someone gets admitted to the hospital and we’re not paying attention to getting them up and doing all of those things that are going to prevent them from being deconditioned, then we put our patients at risk,” she said.
Galles also talked about how important it is to look “10 steps ahead” and do interventions in the ED that will prevent complications down the road.
For instance, another case study highlighted a 64-year-old man with COPD who smoked, abused alcohol, and came into the ED with multiple rib fractures from a motor vehicle crash. Despite the pain of broken ribs, the ED used an incentive spirometer, along with aggressive pain management, to avoid the possible downhill slide of the patient requiring intubation, not coming off the ventilator very well, needing a trach, and eventually extending his hospital stay even longer. Thanks to proactive ED care, the patient was able to go home after a rib plating procedure.
The session showed how APRNs can provide strategies like these to help improve throughput, reduce length of stay and enhance patient care overall.
“Utilize that, tap into that resource,” Galles said of APRNs. “APRNs are hugely important to patient outcomes.”