Emergency department use by nursing home residents

Management of adverse clinical events by duty physicians in a nursing home

BACKGROUND AND AIMS

The nature of adverse clinical events (ACE) during duty hours (16:00-08:00 and holidays), as well as the way they are addressed by duty physicians (DP) in a nursing home (NH) are the subject of this study.

METHODS

Data, including medical details concerning ACEs and the resultant referrals to hospital, were collected prospectively during 183 consecutive days in a 90-bed NH.

RESULTS

Ninety-six residents experienced 370 ACEs, representing an average of one for every 44.5 patient days. The highest rate of events was during evening hours (18:00-21:00). The most prevalent ACE was fever (32%). Most cases (53%) were treated by the DPs on site. No intervention was needed in 19% of cases, whereas 28% of ACEs (104 cases) were referred to the Emergency Room (ER) of a general hospital. Sixty-six percent of these were actually admitted. The rate of ER referral of residents was one for every 158 patient days. About 40% of the referred patients had been discharged from hospital the previous week. High fever was the commonest cause for referral: 47%. During the working hours of the study period, the rate of referral by the staff physician was only 1 for every 915 patient days. Only 17% of these had high fever.

CONCLUSIONS

Evening rounds by staff physicians, strengthening of working relations with hospital physicians, as well as fostering intravenous treatment in NHs, are suggested as means for reducing hospital transfers. A standardized method for the reporting of ACEs and referrals to hospitals should be adopted in order to facilitate comparisons between NHs and to evaluate its use as a quality indicator.

Older patients awaiting emergency department treatment

The aim of this study was to describe, through observations and interviews with patients >/=75 years old and the relatives who accompanied them to the hospital, the conditions at the emergency department (ED) and the events that took place during the waiting period. Twenty older patients were studied, together with their relatives. A modification of a comparative design, the interpretative method 'grounded theory', was utilized. Open, nonparticipant observations were carried out; from the time patients were admitted until the time they were discharged. Patients were observed through all stages, for example, in the reception area, in the examination room, and in the X-ray department. The observations were supplemented with field notes and interviews with the older patients as they left the ED. The selective coding developed into six core-variables that were the focus of the material. These were: unpleasant waiting, unnecessary waiting, lack of good routines during the waiting stage, suffering during the waiting stage, bad feelings during the waiting stage and nursing care during the waiting stage. The way, in which nursing care was carried out, which in this context is discussed in terms of praxis and poieses, appeared to be of major importance for the older peoples' experiences when visiting the ED.

Predictors of Site of Death of End-of-Life Patients: The Importance of Specificity in Advance Directives

Despite the compelling reasons for advance directives and their endorsement by the public and medical professions, little is known about their actual use and impact on site of death. This study was conducted to examine the role of advance directives and other "drivers" of hospitalization of the long-term care end-of-life patient. The medical records of 100 deceased consecutive nursing home residents, stratified by site of death (skilled nursing facility or acute care hospital), were reviewed by a team of geriatric researchers to obtain patient information in the following domains: sociodemographic, advance directives, transfer and death information, patient diagnoses at admission, discharge, and other time intervals; medication usage and signs and symptoms precipitating death. Severity of illness was assessed using the Cumulative Illness Rating Scale-G (CIRS-G). In testing for differences between patients by site of death, sociodemographic variables (gender, age, race, payer at discharge, cognitive capacity) did not significantly differ between the two groups of patients. Strong similarities between the groups were also found in terms of severity of illness and medication usage. Significantly higher proportions of patients dying in the nursing home had specific advance directives (do not resuscitate, do not intubate, do not artificially feed, do not hydrate, and do not hospitalize), as opposed to those dying in the hospital. The findings of this study demonstrate the impact of the explicit advance directive on the decision to transfer the patient to the acute care setting at the end of life.

The Emergency Department Case Manager

The purpose of this research is to examine the effect of having nursing case managers (NCMs) assigned in the emergency department (ED). This research evaluates criteria from the following aspects: inappropriate admissions to the intensive care unit precertification of admissions to the hospital, intensive case unit diversion rates for the hospital, cost savings, and staff and patient satisfaction. The method utilized was a pretest and posttest design examining data on several variables before and after placing the NCMs in the ED. The time frame for the study is 1 year in an urban, 534-bed acute care teaching facility. NCMs were assigned to the ED 7 days a week and were responsible for precertification for admissions and working with physicians to determine that patients are admitted to the most appropriate level of care. Data will be collected through a variety of sources.

Referrals from home care to emergency hospital care: basis for decisions

The Swedish government implemented a reform, the Adel reform, in the care of older citizens in 1992, so that the communities where older people live became responsible for their care and housing. Nurses were appointed to make sure that older people were given accurate care and to act as supervisors for nurses' aides. In this study, 10 Registered Nurses from community home care services and four consultant head physicians in primary care were interviewed in order to illuminate what they thought influenced nurses' decisions to refer patients for emergency treatment and what support they requested to facilitate the decision. Content analysis showed the necessity of feeling secure in one's role as a community nurse. The categories that developed were: own competence, knowledge about the patient and a supportive working environment. The main theme was To feel safe in one's role - a basis for decision-making. High demands were put on the nurses' competence and their burden of responsibility became too great. This influenced decision-making negatively, if nurses felt that they were lacking in their own personal competence. Training in documentation for the nurses was required, as well as the need for organizations to provide staff with sufficient time for accurate documentation. A greater input of nursing and medical care was required to make it possible for patients to be cared for at home if they so wished. Respondents described considerable deficiencies in their working environment and in co-workers' competence, and nurses' professional roles within the community were not made clear. If these problems were remedied, this would improve working conditions, increase understanding, and reduce feelings of uncertainty among decision-makers.

Emergency department case management: the dyad team of nurse case manager and social worker improve discharge planning and patient and staff satisfaction while decreasing inappropriate admissions and costs: a literature review

A model of emergency department (ED) case management consisting of a social worker and a nurse case manager can prevent inappropriate admissions, improve discharge planning, decrease cost, and enhance patient satisfaction. The individual and combined roles of the dyad team of social worker and nurse case manager are discussed. A literature review includes how a case management dyad team of social worker and nurse case manager in the ED can decrease utilization of the ED for nonemergent visits, promote the use of community resources, and improve discharge planning to avoid excessive costs. The importance of the dyad team working with the interdisciplinary team in the ED, the primary care physician (PCP), and other community health care providers in order to provide a holistic approach to care is addressed. A discussion about the improvement of both patient and staff satisfaction demonstrates the results of case management strategies that support and advocate for patients to receive quality, cost-effective care across the health care continuum, while decreasing the use of the ED for nonemergent care.

Obstacles to palliation and end-of-life care in a long-term care facility

PURPOSE

This exploratory study used a set of four obstacle constructs derived from both the existing literature and our earlier work to describe the diverse end-of-life scenarios observed for a group of residents in a long-term care facility.

DESIGN AND METHODS

Data from a retrospective chart review and both quantitative and qualitative methods of data collection and analysis were used to examine in-depth the end-of-life experiences of all nursing home residents (N = 41) who died on the nursing care unit of a large continuing care retirement community during an 18-month period.

RESULTS

A hierarchy of obstacles to palliation and end-of-life care seems to exist in long-term care settings that begins with the lack of recognition that restorative, rehabilitative, or curative treatment futility has commenced. The next three obstacles in sequence include lack of communication among decision makers, no agreement on a course of care, and failure to implement a timely plan of care.

IMPLICATIONS

The findings highlight the importance of determining treatment futility as an initial step in the successful delivery of palliative and end-of-life care to residents in long-term care followed by the need for a deliberate and proactive series of actions and care planning processes.

Emergency department case management: the dyad team of nurse case manager and social worker improve discharge planning and patient and staff satisfaction while decreasing inappropriate admissions and costs: a literature review

A model of emergency department (ED) case management consisting of a social worker and a nurse case manager can prevent inappropriate admissions, improve discharge planning, decrease cost, and enhance patient satisfaction.3 The individual and combined roles of the dyad team of social worker and nurse case manager are discussed. A literature review includes how a case management dyad team of social worker and nurse case manager in the ED can decrease utilization of the ED for nonemergent visits, promote the use of community resources, and improve discharge planning to avoid excessive costs. The importance of the dyad team working with the interdisciplinary team in the ED, the primary care physician (PCP), and other community health care providers in order to provide a holistic approach to care is addressed. A discussion about the improvement of both patient and staff satisfaction demonstrates the results of case management strategies that support and advocate for patients to receive quality, cost-effective care across the health care continuum, while decreasing the use of the ED for nonemergent care.

Percutaneous endoscopic gastrostomy: a prospective analysis of hospital support required and complications following discharge to the community

INTRODUCTION

Percutaneous endoscopic gastrostomy (PEG) is the commonest method of long-term enteral nutrition. In the UK there is no nationally funded framework to provide community support for patients with gastrostomies.

OBJECTIVES

To assess the hospital support required and the complications occurring in a cohort of patients discharged into the community with a gastrostomy in-situ.

DESIGN AND SETTING

We prospectively collected data between June and November 1998 regarding patients (n=87) with PEG complications in the community following discharge from two adjacent hospitals in South Yorkshire (Rotherham District General Hospital and the Royal Hallamshire Hospital).

RESULTS

The mortality within this cohort during the study period was 17.2%. Of these 15 patients 10.3% (n=9) were thought to have died as a result of the progression of their disease, whilst in the other 6.9% (n=6) pneumonia was documented as the cause of death. Problems with gastrostomies requiring telephone advice occurred in 24.1% of patients and 65.5% necessitated a home visit. However during this period of 6 months, 23% of patients were admitted as an emergency, accounting for 61 in-patient days. All were from nursing or residential homes and the emergency occurred after normal surgery hours. General practitioners dealt with aspiration pneumonia in 25.2% of the cohort but other tube problems were referred to the endoscopy unit.

DISCUSSION

This is the first study to specifically highlight the specialist intervention and support required by patients discharged into the community with PEGs, a group for whom there is often no formal aftercare. A specialist nurse or dietician could establish a liaison service focusing on primary care and using hospital resources when appropriate. This study provides further evidence to support the recommendations for tube feeding made by the British Association for Parenteral and Enteral Nutrition.

The LUNAR project: A description of the population of individuals who seek health care at emergency departments

INTRODUCTION

Although little information exists about the consumers of emergency services and their illness behaviors, such information is essential for decision making by providers, administrators, and policy makers. The purpose of the LUNAR Project was to describe the population of individuals who seek health care at emergency departments.

METHODS

After they attended a training course, 90 emergency nurses served as site coordinators in 89 emergency departments in 35 states. A standardized protocol was used to collect data retrospectively from 140 randomly selected patient records at each site. The final sample included 12,422 ED patients.

RESULTS

Overall, 52% of the patient visits were for nonurgent care, 40% were for urgent care, and 8% were for emergent care. Most visits occurred between 10 AM and 8 PM and peaked at 6 PM. Children and younger adults were the largest consumers of services, primarily for nonurgent care. The most frequent reasons for visits were fever, chest pain, and abdominal pain, and the most common discharge diagnoses were middle ear infection, chest pain, and acute upper respiratory infection.

DISCUSSION

The profile of ED patients showed a need for new types of services to provide nonurgent care and new interventions for preventing illnesses and injuries commonly treated in the emergency department.