Frequency and Pattern of Emergency Department Visits by Long-Term Care Residents-A Population-Based Study

Improvements in Antibiotic Appropriateness for Cystitis in Older Nursing Home Residents: A Quality Improvement Study With Randomized Assignment

OBJECTIVE

To determine the impact of an educational quality improvement initiative on the appropriateness of antibiotic prescribing restricted to uncomplicated cystitis in older noncatheterized nursing home residents.

DESIGN

Quality improvement study with randomized assignment.

SETTINGS AND PARTICIPANTS

Twenty-five nursing homes in United States were randomized to the intervention or usual care group by strata that included state, urban/rural status, bed size, and geographic separation.

METHODS

A 12-month trial of a low-intensity multifaceted antimicrobial stewardship intervention focused on uncomplicated cystitis in nursing home residents vs usual care. The outcome was the modified Medication Appropriateness Index as assessed by a blinded geriatric clinical pharmacist and consisted of an assessment of antibiotic effectiveness, dosage, drug-drug interactions, and duration.

RESULTS

There were 75 cases (0.15/1000 resident days) in intervention and 92 (0.22/1000 resident days) in control groups with a probable cystitis per consensus guidelines. Compared with controls, there was a statistically nonsignificant 21% reduction in the risk of inappropriate antibiotic prescribing (nonzero Medication Appropriateness Index score rate 0.13 vs 0.21/1000 person days; adjusted incident rate ratio 0.79; 95% confidence interval 0.45‒1.38). There was a favorable comparison in inappropriateness of duration (77% vs 89% for intervention vs control groups, respectively; P = .0394). However, the intervention group had more problems with drug-drug interactions than the control group (8% vs 1%, respectively; P = .0463). Similarly, the intervention group had a nonsignificant trend toward more problems with dosage (primarily because of the lack of adjustment for decreased renal function) than the control group (32% vs 25%, respectively; P = .3170). Both groups had similar rates of problems with choice/effectiveness (44% vs 45%; P = .9417). The most common class of antibiotics prescribed inappropriately was quinolones (25% vs 23% for intervention versus control groups, respectively; P = .7057).

CONCLUSIONS AND IMPLICATIONS

A low-intensity intervention showed a trend toward improved appropriate antibiotic prescribing in nursing home residents with likely uncomplicated cystitis. Efforts to improve antibiotic prescribing in addition to the low-intensity intervention might include a consultant pharmacist in a nursing home to identify inappropriate prescribing practices.

Emergency transfers of home care patients in Fukui Prefecture, Japan: A retrospective observational study

Little is known about how emergency transfers take place and what outcomes they lead to in the patients who receive home care in Japan. We aimed to assess outcomes of emergency transfers and factors associated with such outcomes in the Japanese home care setting.A retrospective analysis of patient data from a home care clinic in Fukui, Japan, included all patients who experienced emergency transfers which were reported to the clinic during 2018 and 2019. We collected data on patients' sociodemographic and clinical characteristics, as well as the transfer process and its outcome, using patient charts and other administrative records. We first analyzed the overall outcome and then evaluated whether transfer outcomes would differ according to by whom and from where the emergency medical service (EMS) was called, by univariate and multivariate analyses.We considered 63 patients who experienced emergency transfers during the study period. Of the total, 10 (15.9%) returned to their residences without being admitted or being dead on arrival. Although only 2.6% (1/39) of patients whose transfers were determined by health care professionals (HCPs) returned home without being admitted, a direct return was observed for 37.5% (9/24) of patients whose transfer was determined by those other than HCPs (odds ratio of direct return to residences 22.80, 95% confidence interval 2.65-195.87). There was no other variable which was significantly associated with the outcomes after the emergency transfers, although all the patients who have no available caregivers resulted in hospitalization.In this preliminary analysis in the Japanese home care setting, only a small proportion of patients returned to their residences without being admitted following emergency transfers. Patients whose EMS transfer was requested by an HCP usually resulted in an admission to the clinic, whereas transfers requested by non-HCPs frequently did not.

The Safety and Effectiveness of On-Site Paramedic and Allied Health Treatment Interventions Targeting the Reduction of Emergency Department Visits by Long-Term Care Patients: Systematic Review

INTRODUCTION

Programs that seek to avoid emergency department (ED) visits from patients residing in long-term care facilities are increasing. We sought to identify existing programs where allied healthcare personnel are the primary providers of the intervention and, to evaluate their effectiveness and safety.

METHODS

We systematically searched Medline, CINAHL and EMBASE with terms relating to long-term care, emergency services, hospitalization and allied health personnel. We reviewed 11,176 abstracts and included 22 studies in our narrative synthesis, which we grouped by intervention category.

RESULTS

We found five categories of interventions including: 1) use of advanced practice nursing; 2) a program called Interventions to Reduce Acute Care Transfers (INTERACT); 3) end-of-life care; 4) condition specific interventions; and 5) use of extended care paramedics. Among studies measuring that outcome, 13/13 reported a decrease in ED visits, and 16/17 reported a decrease hospitalization in the intervention groups. Patient adverse events such as functional status and relapse were seldom reported (6/22) as were measures of emergency system function such as crowding/inability of paramedics to transfer care to the ED (1/22). Only 4/22 studies evaluated patient mortality and 3/4 found a non-statistically significant worsening.

CONCLUSION

We found five types of programs/interventions which all demonstrated a decrease in ED visits or hospitalization. However, most studies were observational and few assessed patient safety. Many identified programs focused on increased primary care for patients, and interventions addressing acute care issues, such as community paramedics, deserve more study.

Modelling resource requirements and physician staffing to provide virtual urgent medical care for residents of long-term care homes: a cross-sectional study

BACKGROUND

The coronavirus disease 2019 (COVID-19) outbreak increases the importance of strategies to enhance urgent medical care delivery in long-term care (LTC) facilities that could potentially reduce transfers to emergency departments. The study objective was to model resource requirements to deliver virtual urgent medical care in LTC facilities.

METHODS

We used data from all general medicine inpatient admissions at 7 hospitals in the Greater Toronto Area, Ontario, Canada, over a 7.5-year period (Apr. 1, 2010, to Oct. 31, 2017) to estimate historical patterns of hospital resource use by LTC residents. We estimated an upper bound of potentially avoidable transfers by combining data on short admissions (≤ 72 h) with historical data on the proportion of transfers from LTC facilities for which patients were discharged from the emergency department without admission. Regression models were used to extrapolate future resource requirements, and queuing models were used to estimate physician staffing requirements to perform virtual assessments.

RESULTS

There were 235 375 admissions to general medicine wards, and residents of LTC facilities (age 16 yr or older) accounted for 9.3% (n = 21 948) of these admissions. Among the admissions of residents of LTC facilities, short admissions constituted 24.1% (n = 5297), and for 99.8% (n = 5284) of these admissions, the patient received laboratory testing, for 86.9% (n = 4604) the patient received plain radiography, for 41.5% (n = 2197) the patient received computed tomography and for 81.2% (n = 4300) the patient received intravenous medications. If all patients who have short admissions and are transferred from the emergency department were diverted to outpatient care, the average weekly demand for outpatient imaging per hospital would be 2.6 ultrasounds, 11.9 computed tomographic scans and 23.9 radiographs per week. The average daily volume of urgent medical virtual assessments would range from 2.0 to 5.8 per hospital. A single centralized virtual assessment centre staffed by 2 or 3 physicians would provide services similar in efficiency (measured by waiting time for physician assessment) to 7 separate centres staffed by 1 physician each.

INTERPRETATION

The provision of acute medical care to LTC residents at their facility would probably require rapid access to outpatient diagnostic imaging, within-facility access to laboratory services and intravenous medication and virtual consultations with physicians. The results of this study can inform efforts to deliver urgent medical care in LTC facilities in light of a potential surge in COVID-19 cases.

Predicting hospital admission for older emergency department patients: Insights from machine learning

BACKGROUND

Emergency departments (ED) are a portal of entry into the hospital and are uniquely positioned to influence the health care trajectories of older adults seeking medical attention. Older adults present to the ED with distinct needs and complex medical histories, which can make disposition planning more challenging. Machine learning (ML) approaches have been previously used to inform decision-making surrounding ED disposition in the general population. However, little is known about the performance and utility of ML methods in predicting hospital admission among older ED patients. We applied a series of ML algorithms to predict ED admission in older adults and discuss their clinical and policy implications.

MATERIALS AND METHODS

We analyzed the Canadian data from the interRAI multinational ED study, the largest prospective cohort study of older ED patients to date. The data included 2274 ED patients 75 years of age and older from eight ED sites across Canada between November 2009 and April 2012. Data were extracted from the interRAI ED Contact Assessment, with predictors including a series of geriatric syndromes, functional assessments, and baseline care needs. We applied a total of five ML algorithms. Models were trained, assessed, and analyzed using 10-fold cross-validation. The performance of predictive models was measured using the area under the receiver operating characteristic curve (AUC). We also report the accuracy, sensitivity, and specificity of each model to supplement performance interpretation.

RESULTS

Gradient boosted trees was the most accurate model to predict older ED patients who would require hospitalization (AUC = 0.80). The five most informative features include home intravenous therapy, time of ED presentation, a requirement for formal support services, independence in walking, and the presence of an unstable medical condition.

CONCLUSION

To the best of our knowledge, this is the first study to predict hospital admission in older ED patients using a series of geriatric syndromes and functional assessments. We were able to predict hospital admission in older ED patients with good accuracy using the items available in the interRAI ED Contact Assessment. This information can be used to inform decision-making about ED disposition and may expedite admission processes and proactive discharge planning.

Nursing home patients and Emergency Department attendance in a single urban Irish catchment area: an observational study surrounding the introduction of a community medicine for older person service

BACKGROUND

Nursing home (NH) patients are at a high risk of Emergency Department (ED) attendance, and adverse events in the ED. With an increasing NH population, monitoring trends in ED utilization is important to aid service planning, and attention to potentially preventable attendances should be paid, to identify areas that may benefit from specialist support.

AIMS

This 12-year (2008-2019) study aimed to observe trends in ED utilization of NH patients in a single urban Irish catchment area, surrounding the introduction of a Community Medicine for the Older Person (CMOP) outreach program.

METHOD

A retrospective review of all NH attendances within the catchment area was performed based upon NH address. Attendance, admission, discharge, and died in department (DID) were adjusted per annual NH bed numbers (PBC). Trends were observed and compared pre and post the CMOP activation. Comparisons of continuous variables were performed using an unpaired parametric Student's t test.

RESULTS

There were 6877 attendances, with 58% (n = 3989) admitted, 40% (n = 2785) discharged, and 2% (n = 123) DID. There was a statistically significant difference in mean discharge rate PBC pre and post the CMOP introduction (0.22 vs 0.16, P = 0.04). There was no statistically significant difference in attendance, admission, or DID.

CONCLUSION

This is the first Irish study of NH ED utilization over an extended period. ED attendances PBC have not decreased since the introduction of the CMOP. Discharges PBC, however, have decreased and may represent a decrease in potentially preventable attendance/improvement in appropriateness of ED transfers, following the introduction of this intervention.

Citizen and stakeholder led priority setting for long-term care research: identifying research priorities within the Translating Research in Elder Care (TREC) Program

BACKGROUND

The Translating Research in Elder Care (TREC) program is a longitudinal partnered program of research in Western Canada that aims to improve the quality of care and quality of life for residents and quality of worklife for staff in long-term care settings. This program of research includes researchers, citizens (persons living with dementia and caregivers of persons living in long-term care), and stakeholders (representatives from provincial and regional health authorities, owner-operators of long-term care homes). The aim of this paper is to describe how we used priority setting methods with citizens and stakeholders to identify ten priorities for research using the TREC data.

METHODS

We adapted the James Lind Alliance Priority Setting Partnership method to ensure our citizens and stakeholders could identify priorities within the existing TREC data. We administered an online survey to our citizen and stakeholder partners. An in-person priority setting workshop was held in March 2019 in Alberta, Canada to establish consensus on ten research priorities. The in-person workshop used a nominal group technique and involved two rounds of small group prioritization and one final full group ranking.

RESULTS

We received 72 online survey respondents and 19 persons (citizens, stakeholders) attended the in-person priority setting workshop. The workshop resulted in an unranked list of their ten research priorities for the TREC program. These priorities encompassed a range of non-clinical topics, including: influence of staffing (ratios, type of care provider) on residents and staff work life, influence of the work environment on resident outcomes, and the impact of quality improvement activities on residents and staff.

CONCLUSIONS

This modified priority setting approach provided citizens and stakeholders with an opportunity to identify their own research priorities within the TREC program, without the external pressures of researchers. These priorities will inform the secondary analyses of the TREC data and the development of new projects. This modified priority setting may be a useful approach for research teams trying to engage their non-academic partners and to identify areas for future research.

Measuring multimorbidity series-an overlooked complexity comparison of self-report vs. administrative data in community-living adults: paper 2. Prevalence estimates depend on the data source

OBJECTIVE

The objective of the study was to compare multimorbidity prevalence using self-reported and administrative data and identify factors associated with agreement between data sources.

STUDY DESIGN AND SETTING

Self-reported cross-sectional data from four Canadian Community Health Survey waves were linked to administrative data in Ontario, Canada. Multimorbidity prevalence was examined using two definitions, 2+ and 3+ chronic conditions (CCs). Agreement between data sources was assessed using Kappa and Phi statistics. Logistic regression was used to estimate associations between agreement and sociodemographic, health behavior, and health status variables for each multimorbidity definition.

RESULTS

Regardless of multimorbidity definition, prevalence was higher using administrative data (2+ CCs: 55.5% vs. 47.1%; 3+ CCs: 30.0% vs. 24.2%). Agreement between data sources was moderate (2+ CCs K = 0.482; 3+ CCs K = 0.442), and while associated with sociodemographic, health behavior, and health status factors, the magnitude and sometimes direction of association differed by multimorbidity definition.

CONCLUSION

A better understanding is needed of what factors influence individuals' reporting of CCs and how they align with what is in administrative data as policy makers need a solid evidence base on which to make decisions for health planning. Our results suggest that data sources may need to be triangulated to provide accurate estimates of multimorbidity for health services planning and policy.

Effectiveness of hospital avoidance interventions among elderly patients: A systematic review

Objective

Older patients with complex care needs and limited personal and social resources are heavy users of emergency department (ED) services and are often admitted when they present to the ED. Updated information is needed regarding the most effective strategies to appropriately avoid ED presentation and hospital admission among older patients.

Methods

This systematic review aimed to identify interventions that have demonstrated effectiveness in decreasing ED use and hospital admissions in older patients. We conducted a comprehensive literature search within Ovid MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials from database inception to July 2019 with no language restrictions. Interventional study designs conducted in populations of 65 years and older were included. Primary outcomes were ED visits and hospital admissions. Secondary outcomes included hospital readmission, mortality, cost, and patient-reported outcomes.

Results

Of 7,943 citations reviewed for eligibility, 53 studies were included in our qualitative synthesis, including 26 randomized controlled trials (RCT), 8 cluster-RCTs, and 19 controlled before-after studies. Data characterization revealed that community-based strategies reduced ED visits, particularly those that included comprehensive geriatric assessments and home visits. These strategies reported decreases in mean ED use (for interventions versus controls) ranging from -0.12 to -1.32 visits/patient. Interventions that included home visits also showed reductions in hospital admissions ranging from -6% to -14%. There was, however, considerable variability across individual studies with respect to outcome reporting, statistical analyses, and risk of bias, which limited our ability to further quantify the effect of these interventions.

Conclusion

Various interventional strategies to avoid ED presentations and hospital admissions for older patients have been studied. While models of care that include comprehensive geriatric assessments and home visits may reduce acute care utilization, the standardization of outcome measures is needed to further delineate which parts of these complex interventions are contributing to efficacy. The potential effects of multidisciplinary team composition on patient outcomes also warrant further investigation.

"They Don't Trust Us": The Influence of Perceptions of Inadequate Nursing Home Care on Emergency Department Transfers and the Potential Role for Telehealth

In this descriptive, qualitative study, we conducted eight focus groups with diverse informal and formal caregivers to explore their experiences/challenges with nursing home (NH) to emergency department (ED) transfers and whether telehealth might be able to mitigate some of those concerns. Interviews were transcribed and analyzed using a grounded theory approach. Transfers were commonly viewed as being influenced by a perceived lack of trust in NH care/capabilities and driven by four main factors: questioning the quality of NH nurses' assessments, perceptions that physicians were absent from the NH, misunderstandings of the capabilities of NHs and EDs, and perceptions that responses to medical needs were inadequate. Participants believed technology could provide "the power of the visual" permitting virtual assessment for the off-site physician, validation of nursing assessment, "real time" assurance to residents and families, better goals of care discussions with multiple parties in different locations, and family ability to say goodbye.

Perspectives of general practitioners and nursing staff on acute hospital transfers of nursing home residents in Germany: results of two cross-sectional studies

Background

Visits in emergency departments and hospital admissions are common among nursing home (NH) residents and they are associated with significant complications. Many of these transfers are considered inappropriate. This study aimed to compare the perceptions of general practitioners (GPs) and NH staff on hospital transfers among residents and to illustrate measures for improvement.

Methods

Two cross-sectional studies were conducted as surveys among 1121 GPs in the German federal states Bremen and Lower Saxony and staff from 1069 NHs (preferably nursing staff managers) from all over Germany, each randomly selected. Questionnaires were sent in August 2018 and January 2019, respectively. The answers were compared between GPs and NH staff using descriptive statistics, Mann-Whitney U tests and χ2-tests.

Results

We received 375 GP questionnaires (response: 34%) and 486 NH questionnaires (response: 45%). GPs estimated the proportion of inappropriate transfers higher than NH staff (hospital admissions: 35.0% vs. 25.6%, p < 0.0001; emergency department visits: 39.9% vs. 20.9%, p < 0.0001). The majority of NH staff and nearly half of the GPs agreed that NH residents do often not benefit from hospital admissions (NHs: 61.4% vs. GPs: 48.8%; p = 0.0009). Both groups rated almost all potential measures for improvement differently (p < 0.0001), however, GPs and NH staff considered most areas to reduce hospital transfers importantly. The two most important measures for GPs were more nursing staff (91.6%) and better communication between nursing staff and GP (90.9%). NH staff considered better care / availability of GP (82.8%) and medical specialists (81.3%) as most important. Both groups rated similarly the importance of explicit advance directives (GPs: 77.2%, NHs: 72.4%; p = 0.1492).

Conclusions

A substantial proportion of hospital transfers from NHs were considered inappropriate. Partly, the ratings of possible areas for improvement differed between GPs and NH staff indicating that both groups seem to pass the responsibility to each other. These findings, however, support the need for interprofessional collaboration.

Risk of Hospitalization in Long-Term Care Residents Living with Heart Failure: a Retrospective Cohort Study

BACKGROUND

Older adults living with heart failure (HF) in long-term care (LTC) experience frequent hospitalization. Using routinely available clinical information, we examined resident-level factors that precipitate hospitalization within 90 days of admission to LTC.

METHODS

This was a retrospective cohort study of older adults diagnosed with HF, who were admitted to LTC in Ontario, Canada, between 2011 and 2013. Multivariate logistic regression models using generalized estimating equations were developed to determine predictors of hospitalization in residents with HF.

RESULTS

Entry to LTC from a hospital was the strongest predictor of future hospitalization (OR: 8.1, 95% CI: 7.1-9.3), followed by a score of three or greater on the Changes in Health, End-stage Signs and Symptoms scale, a measure of moderate to severe medical instability (O.R 4.2, 95% CI: 3.1-5.9). Other variables that increased the likelihood of hospitalization included being flagged as a high risk for falls, two or more physician visits, and increased monitoring for acute medical illness within 14 days of admission.

CONCLUSION

Our findings highlight that health instability and transitions from acute to LTC will increase the likelihood of transitioning back into the hospital setting. The identified predisposing factors suggest the need for targeted prevention strategies for those in high-risk groups.

Sex-Specific Differences in End-of-Life Burdensome Interventions and Antibiotic Therapy in Nursing Home Residents With Advanced Dementia

Importance

Nursing home residents with advanced dementia have limited life expectancies yet are commonly subjected to burdensome interventions at the very end of life. Whether sex-specific differences in the receipt of these interventions exist and what levels of physical restraints and antibiotics are used in this terminal setting are unknown.

Objective

To evaluate the population-based frequency, factors, and sex differences in burdensome interventions and antibiotic therapy among nursing home residents with advanced dementia.

Design, Setting, and Participants

This population-based cohort study from Ontario, Canada, used linked administrative databases held at ICES, including the Continuing Care Resident Reporting System Long-Term Care database, which contains data from the Resident Assessment Instrument Minimum Data Set, version 2.0. Nursing home residents (n = 27 243) with advanced dementia who died between June 1, 2010, and March 31, 2015, at 66 years or older were included in the analysis. Initial statistical analysis was completed in May 2017, and analytical revisions were conducted from November 2018 to January 2019.

Exposure

Sex of the nursing home resident.

Main Outcomes and Measures

Burdensome interventions (transitions of care, invasive procedures, and physical restraints) and antibiotic therapy in the last 30 days of life.

Results

The final cohort included 27 243 nursing home residents with advanced dementia (19 363 [71.1%] women) who died between June 1, 2010, and March 31, 2015, at the median (interquartile range) age of 88 (83-92) years. In the last 30 days of life, burdensome interventions were common, especially among men: 5940 (21.8%) residents were hospitalized (3661 women [18.9%] vs 2279 men [28.9%]; P < .001), 2433 (8.9%) had an emergency department visit (1579 women [8.2%] vs 854 men [10.8%]; P < .001), and 3701 (13.6%) died in an acute care facility (2276 women [11.8%] vs 1425 men [18.1%]; P < .001). Invasive procedures were also common; 2673 residents (9.8%) were attended for life-threatening critical care (1672 women [8.6%] vs 1001 men [12.7%]; P < .001), and 210 (0.8%) received mechanical ventilation (113 women [0.6%] vs 97 men [1.2%]; P < .001). Among the 9844 residents (36.1%) who had a Resident Assessment Instrument Minimum Data Set, version 2.0, completed in the last 30 days of life, 2842 (28.9%) were physically restrained (2002 women [28.3%] vs 840 men [30.4%]; P = .005). More than one-third (9873 [36.2%]) of all residents received an antibiotic (6599 women [34.1%] vs 3264 men [41.4%]; P < .001). In multivariable models, men were more likely to have a transition of care (adjusted odds ratio, 1.41; 95% CI, 1.33-1.49; P < .001) and receive antibiotics (adjusted odds ratio, 1.33; 95% CI, 1.26-1.41; P < .001). Only 3309 residents (12.1%; 2382 women [12.3%] vs 927 men [11.8%]) saw a palliative care physician in the year before death, but those who did experienced greater than 50% lower odds of an end-of-life transition of care (adjusted odds ratio, 0.48; 95% CI, 0.43-0.54); P < .001) and greater than 25% lower odds of receiving antibiotics (adjusted odds ratio, 0.74; 95% CI, 0.68-0.81; P < .001).

Conclusions and Relevance

In this study, many nursing home residents with advanced dementia, especially men, received burdensome interventions and antibiotics in their final days of life. These findings appear to emphasize the need for sex-specific analysis in dementia research as well as the expansion of palliative care and end-of-life antimicrobial stewardship in nursing homes.

Unplanned index hospital admissions among new older high-cost health care users in Ontario: a population-based matched cohort study

BACKGROUND

Most health care spending is concentrated within a small group of high-cost health care users. To inform health policies, we examined the characteristics of index hospital admissions and their predictors among incident older high-cost users compared to older non-high-cost users in Ontario.

METHODS

Using Ontario administrative data, we identified incident high-cost users aged 66 years or more and matched them 1:3 on age, gender and Local Health Integration Network with non-high-cost users aged 66 years or more. We defined high-cost users as patients within the top 5% most costly high-cost users during fiscal year 2013/14 but not during 2012/13. An index hospital admission, the main outcome, was defined as the first unplanned hospital admission during 2013/14, with no hospital admissions in the preceding 12 months. Descriptively, we analyzed the attributes of index hospital admissions, including costs. We identified predictors of index hospital admissions using stratified logistic regression.

RESULTS

Over half (95 375/175 847 [54.2%]) of all high-cost users had an unplanned index hospital admission, compared to 8838/527 541 (1.7%) of non-high-cost users. High-cost users had a poorer health status, longer acute length of stay (mean 7.5 d v. 2.9 d) and more frequent designation as alternate level of care before discharge (20.8% v. 1.7%) than did non-high-cost users. Ten diagnosis codes accounted for roughly one-third of the index hospital admission costs in both cohorts. Although many predictors were similar between the cohorts, a lower risk of an index hospital admission was associated with residence in long-term care, attachment to a primary care provider and recent consultation by a geriatrician among high-cost users.

INTERPRETATION

The high prevalence of index hospital admissions and the corresponding costs are a distinctive feature of incident older high-cost users. Improved access to specialist outpatient care, home-based social care and long-term care when required are worth further investigation.

Lung Ultrasound for Initial Diagnosis and Subsequent Monitoring of Aspiration Pneumonia in Elderly in Home Medical Care Setting

The number of aspiration pneumonia cases has increased in recent times. A definitive diagnosis of aspiration pneumonia is difficult in resource-limited settings where radiological equipment is unavailable. We report the initial diagnosis and subsequent monitoring of aspiration pneumonia in a home medical care setting. An 88-year-old Japanese male presented an acute onset of dyspnea, fever, and productive cough. At home, lung ultrasound displayed pleural effusion along with B-lines and subpleural consolidations. Upon admission, tests revealed increased total leucocyte counts with left-shifted neutrophils, elevated C-reactive protein levels, and positive sputum Gram stain. Chest X-ray imaging and computed tomography (CT) showed bibasilar infiltrates and wall thickening in the left S10 bronchi. The patient was diagnosed with aspiration pneumonia and treated with an antibiotic. After a 10-day hospitalization, lung ultrasound showed some remaining B-lines and disappearance of pleural effusion and subpleural consolidation. Chest X-ray image was normal, and CT revealed pleural abnormality and disappearance of bibasilar infiltrates, consistent with the ultrasound findings. Aspiration pneumonia develops with various clinical signs. However, diagnosis using chest X-ray imaging or CT in resource-limited settings is difficult. Ultrasound might allow physicians to make more accurate judgments, particularly while monitoring aspiration pneumonia following initial diagnosis in resource-limited settings.

Insights on multimorbidity and associated health service use and costs from three population-based studies of older adults in Ontario with diabetes, dementia and stroke

Background

Most studies that examine comorbidity and its impact on health service utilization focus on a single index-condition and are published in disease-specific journals, which limit opportunities to identify patterns across conditions/disciplines. These comparisons are further complicated by the impact of using different study designs, multimorbidity definitions and data sources. The aim of this paper is to share insights on multimorbidity and associated health services use and costs by reflecting on the common patterns across 3 parallel studies in distinct disease cohorts (diabetes, dementia, and stroke) that used the same study design and were conducted in the same health jurisdiction over the same time period.

Methods

We present findings that lend to broader Insights regarding multimorbidity based on the relationship between comorbidity and health service use and costs seen across three distinct disease cohorts. These cohorts were originally created using multiple linked administrative databases to identify community-dwelling residents of Ontario, Canada with one of diabetes, dementia, or stroke in 2008 and each was followed for health service use and associated costs.

Results

We identified 376,434 indviduals wtih diabetes, 95,399 wtih dementia, and 29,671 with stroke. Four broad insights were identified from considering the similarity in comorbidity, utilization and cost patterns across the three cohorts: 1) the most prevalent comorbidity types were hypertension and arthritis, which accounted for over 75% of comorbidity in each cohort; 2) overall utilization increased consistently with the number of comorbidities, with the vast majority of services attributed to comorbidity rather than the index conditions; 3) the biggest driver of costs for those with lower levels of comorbidity was community-based care, e.g., home care, GP visits, but at higher levels of comorbidity the driver was acute care services; 4) service-specific comorbidity and age patterns were consistent across the three cohorts.

Conclusions

Despite the differences in population demographics and prevalence of the three index conditions, there are common patterns with respect to comorbidity, utilization, and costs. These common patterns may illustrate underlying needs of people with multimorbidity that are often obscured in literature that is still single disease-focused.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4149-3) contains supplementary material, which is available to authorized users.

Regional variations of care in home care and long-term care: a retrospective cohort study

BACKGROUND

Many aging adults undergo progressive loss of autonomy, develop increasingly complex medical needs and experience multiple care transitions. We sought to determine the degree of variation in rates of transfer from home care services and long-term care in several Canadian jurisdictions.

METHODS

In this retrospective cohort study, we examined transitions from home care services and long-term care to different possible end states: change in health stability (getting better or worse), transfer to hospital, transfer to another care setting or death. We used standardized interRAI assessments from long-term care and home care linked to hospital records (data from the Discharge Abstract Database and National Ambulatory Care Reporting System) from 2010 to 2016. Multistate modelling was used to adjust for patients with complex health status and transitions in care.

RESULTS

We report data for 254 664 patients in home care programs and 162 045 residents in long-term care. Compared with patients in Ontario, patients requiring home care services in Alberta and British Columbia had increased odds of being admitted to hospital regardless of the underlying severity of illness (the adjusted odds ratios [OR] ranged from 2.08 to 3.77 in Alberta and from 1.28 to 1.46 in BC). Residents in long-term care in Alberta and BC had less than half the odds of being transferred to hospital, independent of all other factors, when compared with long-term care residents in Ontario (the adjusted OR ranged from 0.38 to 0.39 in Alberta and from 0.33 to 0.44 in BC).

INTERPRETATION

Significant variations in transfer rates were observed between provinces, even after controlling for individual patient characteristics. These results suggest that transfers to hospital are largely driven by health care policies, health care professional practice patterns and available infrastructure rather than individual patient needs.

Models of care that avoid or improve transitions to hospital services for residential aged care facility residents: An integrative review

Care transitions for older people moving from residential aged care facilities (RACFs) to hospital services are associated with greater challenges and poorer outcomes. An integrative review was conducted to investigate models of care designed to avoid or improve transitions for older people residing in RACFs to hospital settings. Twenty-one studies were included in the final analysis. Models of care aimed to either improve or avoid transitions of residents through enhanced primary care in RACFs, promoting quality improvement in RACFs, instilling comprehensive hospital care, conducting outreach services, transferring information, or involved a combination of outreach services and comprehensive hospital care. As standalone interventions, standardised communication tools may improve information transfer between RACFs and hospital services. For more complex models, providing quality improvement and outreach to RACFs may prevent some types of hospital admissions.

Urinary infection in the elderly

INTRODUCTION

Urinary tract infections (UTIs) are one of the most frequent infections. In the elderly, they have multiple comorbidities. The objective of this work is to describe the clinical and microbiological epidemiology of elderly persons admitted for UTIs and to evaluate the suitability of empirical treatments and their implications regarding mortality.

MATERIAL AND METHODS

An observational study was conducted during 2013-2015 in 4public hospitals, with patients older than 65 years who were admitted to the Internal Medicine service with a microbiological diagnosis of UTI. Cases of asymptomatic bacteriuria were excluded. In-hospital mortality was analyzed. Univariate analysis and multivariate analysis was carried out.

RESULTS

A total of 349 episodes were selected, with a mean age of 82 ± 11 years, 51% female. Mortality was 10.3% and was associated with age, dementia and sepsis and septic shock (P<.05). The most frequent organisms were Escherichia coli(E. coli) (53.6%), Klebsiella spp. (8.7%) and Enterococcus spp. (6.6%). E. coli and Klebsiella spp. with extended-spectrum beta-lactamases (13% of the total isolated) were associated with the previous use of antibiotics, community care treatment and a permanent urinary catheter (P<.05). The empirical treatment was adequate only in 73.6% of cases. As these treatments were associated with higher mortality, they were not considered adequate.

CONCLUSIONS

In the elderly, UTIs show a high mortality. Empirical treatment is often inadequate and may be associated with increased mortality.

Patient Transfer Decision Difficulty Scale: Development and psychometric testing of emergency department visits by long-term care residents

Background and objectives

Nurses serve as gatekeepers of the health of long-term care facility (LTCF) residents and are key members deciding whether residents should visit an emergency department (ED). Inappropriate decisions as to ED visits may result in ED overcrowding, excessive medical expenses, and nosocomial infections. Currently, there is a lack of effective tools for assessing the barriers and level of difficulty experienced by LTCF nurses. The purposes of this study were to develop a Patient Transfer Decision Difficulty Scale (PTDDS) and test its effectiveness.

Methods

This study randomly sampled LTCFs in Taiwan and surveyed two or three nurses in every institution selected. Registered return envelopes were provided for participants to return self-completed questionnaires. Three steps were used to develop the scale and items: in step I, the instrument was developed; in step II, psychometric testing was conducted, which entailed performing an exploratory factor analysis (EFA) to verify the construct validity and reliability of the developed items; and in step III, a confirmation study was conducted using a confirmatory factor analysis (CFA) and structural equation modeling to cross-validate the factors and items.

Results

The cumulative sum of variance explained by the measurement models of the three factors in the PTDDS was 63.54%.When deciding whether to transfer LTCF residents to EDs, the most pronounced barrier experienced by nurses were for judging the severity of “clinical episodes”, which had an explanatory power of 37.49%. The second and third pronounced barriers and decision difficulty experienced by nurses were “communication and information” and “timing of the residents’ emergency visits,” which explained 16.81% and 9.24% of the variance, respectively.

Conclusions

The cross-validation results obtained using the EFA and CFA showed favorable reliability and validity of the PTDDS. For future studies, this study recommends performing large-scale investigations of the level of decision difficulty and related factors experienced by nurses in LTCFs of varying levels and types.

Appropriateness of transferring nursing home residents to emergency departments: a systematic review

Background

Elderly living in a Nursing Home (NH) are frequently transferred to an Emergency Department when they need acute medical care. A proportion of these transfers may be considered inappropriate and may be avoidable.

Methods

Systematic review. Literature search performed in September 2018 using PubMed, Web of Science, the Cochrane Library and the Cumulative Index to Nursing and Allied Health Literature database. Titles and abstracts were screened against inclusion and exclusion criteria. Full-texts of the selected abstracts were read and checked for relevance. All years and all languages were included provided there was an English, French, Dutch or German abstract.

Results

Seventy-seven articles were included in the systematic review: 1 randomised control trial (RCT), 6 narrative reviews, 9 systematic reviews, 7 experimental studies, 10 qualitative studies and 44 observational studies. Of all acute transfers of NH residents to an ED, 4 to 55% were classified as inappropriate. The most common reasons for transfer were trauma after falling, altered mental status and infection. Transfers were associated with a high risk of complications and mortality, especially during out-of-hours. Advance directives (ADs) were usually not available and relatives often urge NH staff to transfer patients to an ED. The lack of availability of GPs was a barrier to organise acute care in the NH in order to prevent admission to the hospital.

Conclusions

The definition of appropriateness is not uniform across studies and needs further investigation. To avoid inappropriate transfer to EDs, we recommend to respect the patient’s autonomy, to provide sufficient nursing staff and to invest in their education, to increase the role of GPs in the care of NH residents both in standard and in acute situations, and to promote interprofessional communication and collaboration between GPs, NH staff and EDs.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1028-z) contains supplementary material, which is available to authorized users.

How much emergency department use by vulnerable populations is potentially preventable?: A period prevalence study of linked public hospital data in South Australia

OBJECTIVES

To quantify emergency department (ED) presentations by individuals within vulnerable populations compared with other adults and the extent to which these are potentially preventable.

DESIGN

Period prevalence study from 2005-2006 to 2010-2011.

SETTING

Person-linked, ED administrative records for public hospitals in South Australia.

PARTICIPANTS

Adults aged 20 or more in South Australia's metropolitan area presenting to ED and categorised as Refugee and Asylum Seeker Countries of birth (RASC); Aboriginal; those aged 75 years or more; or All others.

MAIN OUTCOME MEASURES

Unadjusted rates of ambulatory care sensitive condition (ACSC), general practitioner (GP)-type presentations and associated direct ED costs among mutually exclusive groups of individuals.

RESULTS

Disparity between RASC and All others was greatest for GP-type presentations (423.7 and 240.1 persons per 1000 population, respectively) with excess costs of $A106 573 (95% CI $A98 775 to $A114 371) per 1000 population. Aboriginal had highest acute ACSC presenter rates (125.8 against 51.6 per 1000 population) with twice the risk of multiple presentations and $A108 701 (95% CI $A374 to $A123 029) per 1000 excess costs. Those aged 75 or more had highest chronic ACSC presenter rates (119.7vs21.1 per 1000), threefold risk of further presentations (incidence rate ratio 3.20, 95% CI 3.14 to 3.26) and excess cost of $A385 (95% CI $A178 160 to $A184 609) per 1000 population.

CONCLUSIONS

Vulnerable groups had excess ED presentations for a range of issues potentially better addressed through primary and community healthcare. The observed differences suggest inequities in the uptake of effective primary and community care and represent a source of excess cost to the public hospital system.

Mind the gap: is the Canadian long-term care workforce ready for a palliative care mandate?

The average expected lifespan in Canadian long-term care (LTC) homes is now less than two years post-admission, making LTC a palliative care setting. As little is known about the readiness of LTC staff in Canada to embrace a palliative care mandate, the main objective of this study was to assess qualities relevant to palliative care, including personal emotional wellbeing, palliative care self-efficacy and person-centred practices (e.g. knowing the person, comfort care). A convenience sample of 228 professional and non-professional staff (e.g. nurses and nursing assistants) across four Canadian LTC homes participated in a survey. Burnout, secondary traumatic stress and poor job satisfaction were well below accepted thresholds, e.g. burnout: mean = 20.49 (standard deviation (SD) = 5.39) for professionals; mean = 22.09 (SD = 4.98) for non-professionals; cut score = 42. Furthermore, only 0–1 per cent of each group showed a score above cut-off for any of these variables. Reported self-efficacy was moderate, e.g. efficacy in delivery: mean = 18.63 (SD = 6.29) for professionals; mean = 15.33 (SD = 7.52) for non-professionals; maximum = 32. The same was true of self-reported person-centred care, e.g. knowing the person; mean = 22.05 (SD = 6.55) for professionals; mean = 22.91 (SD = 6.16) for non-professionals; maximum = 35. t-Tests showed that non-professional staff reported relatively higher levels of burnout, while professional staff reported greater job satisfaction and self-efficacy (p < 0.05). There was no difference in secondary traumatic stress or person-centred care (p > 0.05). Overall, these results suggest that the emotional wellbeing of the Canadian LTC workforce is unlikely to impede effective palliative care. However, palliative care self-efficacy and person-centred care can be further cultivated in this context.

Building Capacity in Long-Term Care: Supporting Homes to Provide Intravenous Therapy

Background

Typically, long-term care home (LTCH) residents are transferred to hospital to access intravenous (IV) therapy. The aim of this study was to pilot-test an in-home IV therapy service, and to describe outcomes and key informants’ perceptions of this service.

Method

This service was pilot-tested in four LTCH in the Hamilton-Niagara region, Ontario. Interviews were conducted with six caregivers of residents who received IV therapy and ten key informants representing LTC home staff and service partners to assess their perceptions of the service. A chart review was conducted to describe the resident population served and service implementation.

Results

Twelve residents received IV therapy. This service potentially avoided nine emergency department visits and reduced hospital lengths of stay for three residents whose IV therapy was initiated in hospital. There were no adverse events. The service was well received by caregivers and key informants, as it provided care in a familiar environment and was perceived to be less stressful and better quality care than when provided in hospital.

Conclusion

IV therapy is feasible to implement in LTCHs, particularly when there are supportive resources available and clinical pathways to support decision-making. This service has the potential to increase capacity in LTCHs to provide medical care.

Predicting Future Health Transitions Among Newly Admitted Nursing Home Residents With Heart Failure

OBJECTIVES

To understand how a heart failure diagnosis and admission health instability predict health transitions and outcomes among newly admitted nursing home residents.

DESIGN

Retrospective cohort study of linked administrative data, including the Continuing Care Report System MDS 2.0 for nursing homes, the Discharge Abstract Database for hospitalized patients, and National Ambulatory Care Reporting System to track emergency department visits.

SETTING AND PARTICIPANTS

Older adults, aged 65 years and above, admitted to nursing homes in Ontario, Alberta, and British Columbia, Canada, from 2010 to 2016.

MEASURES

Mortality and hospitalization were plotted over 1 year. Multistate Markov models were used to estimate adjusted odds ratios (ORs) for transitions to different states of health in stability, hospitalization, and death, stratified by heart failure diagnosis and by interRAI Changes in Health and End-stage disease Signs and Symptoms (CHESS) score, at 90 days following admission to a nursing home.

RESULTS

The final sample included 143,067 residents. Adverse events were most common in the first 90 days. A diagnosis of heart failure predicted worsening health instability, hospitalizations, and mortality. The effect of heart failure on hospitalizations and death was strongest for low baseline health instability (CHESS = 0; OR 1.63, 95% confidence interval (CI) 1.58-1.68, and OR 1.71, 95% CI 1.57-1.86, respectively), versus moderate instability (CHESS = 1-2; OR 1.36, 95% CI 1.32-1.39, and OR 1.48, 95% CI 1.41-1.55), versus high instability (CHESS = 3; OR 1.12, 95% CI 1.03-1.23, and OR 1.21, 95% CI 1.11-1.32). The magnitude of the impact of a heart failure diagnosis was greatest for lower baseline health instability. Residents with the highest degree of health instability were also most likely to die in hospital.

CONCLUSIONS AND IMPLICATIONS

A diagnosis of heart failure and health instability provide complementary information to predict transfers, deaths, and adverse outcomes. Clearly identifying these at-risk patients may be useful in targeting interventions in nursing homes.

The proportion, conditions, and predictors of emergency department visits that can be potentially managed by pharmacists with expanded scope of practice

BACKGROUND

Pharmacists have been shown to be beneficial for inclusion in emergency department (ED) services; however, little has been done to assess these benefits with pharmacists having even wider scopes of practice, including limited prescribing authority.

OBJECTIVES

The aims of this study were to determine the proportion of ED visits that can potentially be managed by pharmacists, the most prevalent conditions within these cases, and the factors associated with patients presenting with such cases to the ED.

METHODS

This was a retrospective quantitative cohort study using administrative databases from 2010 to 2017. Among all unscheduled ED visits in Ontario, all visits with a Family Practice Sensitive Condition and Canadian Triage and Acuity Scale score of IV or V were identified, in addition to conditions that can be managed by pharmacists with expanded scope. Logistic regression was performed to identify determinants of having a potentially pharmacist-manageable condition.

RESULTS

Of 34,550,020 ED visits identified, 12.4% (n = 4,293,807) were considered FPSC with CTAS IV or V. Of these, 1,494,887 (34.8%) were for conditions considered to be potentially manageable by pharmacists, representing 4.3% of all ED visits. The most frequent diagnoses observed were: acute pharyngitis, conjunctivitis, rash and other nonspecific skin eruption, otitis externa, cough, acute sinusitis, and dermatitis. Female gender, having a family physician or presenting with a CTAS of IV were associated with higher odds of presenting to the ED, while increased age and income were associated with lower odds.

CONCLUSIONS

Under an expanded scope, pharmacists could potentially have managed nearly 1.5 million cases presenting to the ED over the study period. The introduction of ED-based or community pharmacists practicing under an expanded scope may have a positive impact on overcrowding in EDs.

Acute Care Use for Ambulatory Care-Sensitive Conditions in High-Cost Users of Medical Care with Mental Illness and Addictions

OBJECTIVE

The role of mental illness and addiction in acute care use for chronic medical conditions that are sensitive to ambulatory care management requires focussed attention. This study examines how mental illness or addiction affects risk for repeat hospitalization and/or emergency department use for ambulatory care-sensitive conditions (ACSCs) among high-cost users of medical care.

METHOD

A retrospective, population-based cohort study using data from Ontario, Canada. Among the top 10% of medical care users ranked by cost, we determined rates of any and repeat care use (hospitalizations and emergency department [ED] visits) between April 1, 2011, and March 31, 2012, for 14 consensus established ACSCs and compared them between those with and without diagnosed mental illness or addiction during the 2 years prior. Risk ratios were adjusted (aRR) for age, sex, residence, and income quintile.

RESULTS

Among 314,936 high-cost users, 35.9% had a mental illness or addiction. Compared to those without, individuals with mental illness or addiction were more likely to have an ED visit or hospitalization for any ACSC (22.8% vs. 19.6%; aRR, 1.21; 95% confidence interval [CI], 1.20-1.23). They were also more likely to have repeat ED visits or hospitalizations for the same ACSC (6.2% vs. 4.4% of those without; aRR, 1.48; 95% CI, 1.44-1.53). These associations were stronger in stratifications by mental illness diagnostic subgroup, particularly for those with a major mental illness.

CONCLUSIONS

The presence of mental illness and addiction among high-cost users of medical services may represent an unmet need for quality ambulatory and primary care.

Characterizing the Long-term Care and Community-dwelling Elderly Patients' Use of the Emergency Department

Introduction

Elderly patients, particularly those in long-term care (LTC), are a growing proportion of patients who present to the emergency department (ED). This population is medically complex, with high burdens on ED resources and patient flow. This study sought to characterize how elderly LTC and community-dwelling (CD) patients use ED services. 

Materials and methods

This was a retrospective cohort study that assessed approximately 200 senior (age>65) ED visits. These patients were either residing in LTC facilities or they were CD. All participants lived in the same, medium-sized Canadian city. Data indicating demographic information, acuity of presentation, and administrative parameters (such as disposition status or length of stay) were collected and analyzed.

Results

A few statistically significant differences between the populations were noted. This included mean age, which was 82.6 years in the LTC population and 77.3 for the CD group (p<0.001). There were 27 repeat visits among patients in the LTC group, compared to six from the CD patients (p<0.001). In the LTC population, 75 patients required transport from emergency medical services (EMS) compared to 41 from the control group (p<0.001).

Conclusion

LTC patients re-present to the ED and use EMS services more frequently than their CD counterparts. This difference indicates potential areas to target for future quality improvement work to help enhance care to this vulnerable population.

Fractured Care: A Window Into Emergency Transitions in Care for LTC Residents With Complex Health Needs

Objective: For long-term care (LTC) residents, transfers to emergency departments (EDs) can be associated with poor health outcomes. We aimed to describe characteristics of residents transferred, factors related to decisions during transfer, care received in emergency medical services (EMS), ED settings, outcomes on return to LTC, and times of transfer segments along the transition. Method: We prospectively followed 637 transitions to an ED in British Columbia and Alberta, Canada, over a 12-month period. Data were captured through an electronic Transition Tracking Tool and interviews with health care professionals. Results: Common events triggering transfer were falls (26.8%), sudden change in condition (23.5%), and shortness of breath (19.8%). Discrepancies existed between reason for transfer, EMS reported chief complaint, and ED diagnosis. Many transfers resulted in resident return directly to LTC (42.7%). Discussion: Avoidable transfers may put residents at risk of receiving inappropriate care. Standardized communication strategies to highlight changes in resident condition are warranted.

Monitoring Health Status in Long Term Care Through the Use of Ambient Technologies and Serious Games

New technologies, such as serious games and ambient activities, are being developed to address problems of under-stimulation, anxiety, and agitation in millions of people living with dementia in long term care homes. Frequent interactions with instrumented versions of these technologies may not only be beneficial for long term care residents, but may also provide a valuable new set of multifaceted data related to the health status of residents over time. In this paper, we develop a model for health monitoring in healthcare environments and we report on two studies that show how medically relevant data can be collected from elderly residents and emergency department patients in an unobtrusive way. The first study shows how data related to cognitive abilities can be collected from elderly emergency department patients and the second study shows how detailed data on a range of factors can be collected from ambient activity units designed to provide engaging interactions for long term care residents. In summary, this paper proposes the use of new technologies to transform long term care from a data poor to a data rich environment, where the health status of long term care residents and elderly patients is more closely monitored.

Repeat emergency department visits by nursing home residents: a cohort study using health administrative data

BACKGROUND

Nursing home (NH) residents are frequent users of emergency departments (ED) and while prior research suggests that repeat visits are common, there is little data describing this phenomenon. Our objectives were to describe repeat ED visits over one year, identify risk factors for repeat use, and characterize "frequent" ED visitors.

METHODS

Using provincial administrative data from Ontario, Canada, we identified all NH residents 65 years or older who visited an ED at least once between January 1 and March 31, 2010 and then followed them for one year to capture all additional ED visits. Frequent ED visitors were defined as those who had 3 or more repeat ED visits. We used logistic regression to estimate risk factors for any repeat ED visit and for being a frequent visitor and Andersen-Gill regression to estimate risk factors for the rate of repeat ED visits.

RESULTS

In a cohort of 25,653 residents (mean age 84.5 (SD = 7.5) years, 68.2% female), 48.8% had at least one repeat ED visit. Residents who experienced a repeat ED visit were generally similar to others but they tended to be slightly younger, have a higher proportion male, and a higher proportion with minimal cognitive or physical impairment. Risk factors for a repeat ED visit included: being male (adjusted odds ratio 1.27, (95% confidence interval 1.19-1.36)), diagnoses such as diabetes (AOR 1.28 (1.19-1.37)) and congestive heart failure (1.26 (1.16-1.37)), while severe cognitive impairment (AOR 0.92 (0.84-0.99)) and 5 or more chronic conditions (AOR 0.82 (0.71-0.95)) appeared protective. Eleven percent of residents were identified as frequent ED visitors, and they were more often younger then 75 years, male, and less likely to have Alzheimer's disease or other dementias than non-frequent visitors.

CONCLUSIONS

Repeat ED visits were common among NH residents but a relatively small group accounted for the largest number of visits. Although there were few clear defining characteristics, our findings suggest that medically complex residents and younger residents without cognitive impairments are at risk for such outcomes.

Age and sex differences in emergency department visits of nursing home residents: a systematic review

Background

Nursing home residents (NHRs) are often transferred to emergency departments (EDs). A great proportion of ED visits is considered inappropriate. There is evidence that male NHRs are more often hospitalised, but this is less clear for ED visits. It is unclear, which influence age has on ED visits. We aimed to study the epidemiology of ED visits in NHRs focusing on age- and sex-specific differences.

Methods

A systematic review was carried out based on articles found in MEDLINE (via PubMed), CINAHL and Scopus. Articles published on or before Aug 31, 2017 were eligible. Two reviewers independently identified articles for inclusion. The quality of studies was assessed by the Joanna Briggs Institute critical appraisal tool for prevalence studies.

Results

Out of 1192 references, we found seven studies meeting our inclusion criteria. Six studies were conducted in the USA or Canada. Overall, 29–62% of NHRs had at least one ED visit over the course of 1 year. Most studies assessing the influence of sex found that male residents visited EDs more frequently. All but one of the five studies with multivariable analyses reported a statistically significant positive association (with odds or rate ratios of 1.05–1.38). All studies assessed the influence of age. There was no clear pattern with some studies showing no association between ED visits and age and other studies reporting decreasing ED visits with increasing age or increasing proportions followed by a decrease in the highest age group. Studies used 85+ or 86+ years as the highest age category. Hospital admission rate ranged from 36.4 to 48.7%. There was no study reporting stratified analyses by age and sex. Only one study reported main diagnoses leading to ED visits stratified by sex.

Conclusion

Male NHRs visit EDs more often than females, but there is no evidence on reasons. The association with age is unclear. Any future study on acute care of NHRs should assess the influence of age and sex. These studies should include large sample sizes to provide a more differentiated age categorisation.

Trial registration

PROSPERO CRD42017074845.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0848-6) contains supplementary material, which is available to authorized users.

GeriMedRisk, a telemedicine geriatric pharmacology consultation service to address adverse drug events in long-term care: a stepped-wedge cluster randomized feasibility trial protocol (ISRCTN17219647)

Background

Multimorbidity, polypharmacy, and older age predispose seniors to adverse drug events (ADE). Seniors with an ADE experience greater morbidity, mortality, and health care utilization compared to their younger counterparts. To mitigate and manage ADEs among this vulnerable population, we designed a geriatric pharmacology consultation service connecting clinicians with specialist physicians and pharmacists and will investigate the feasibility and acceptability of this complex intervention in the long-term care setting, prior to conducting a larger efficacy trial.

Methods/Design

We will conduct a cluster randomized feasibility trial and qualitative analysis of GeriMedRisk among four long-term care homes in the Waterloo-Wellington region from May 1 to December 31, 2017. The primary outcome is the feasibility and acceptability of GeriMedRisk and the stepped-wedge cluster randomized controlled trial design. We hypothesize that GeriMedRisk is a feasible intervention and its potential to decrease falls and drug-related hospital visits can be evaluated with a stepped-wedge cluster randomized controlled trial design.

Discussion

This mixed methods study will inform a larger efficacy trial of GeriMedRisk's ability to decrease adverse drug events among seniors in the long-term care setting.

Ethics and dissemination

The Hamilton Integrated Research Ethics Board granted the approval for this study protocol 2812. We plan to disseminate the results of this study in peer-reviewed journals and also to our partners and stakeholders.

Trial registration

ISRCTN clinical trials registry, ISRCTN17219647 (March 27, 2017).

How well does the minimum data set measure healthcare use? a validation study

Background

To improve care, planners require accurate information about nursing home (NH) residents and their healthcare use. We evaluated how accurately measures of resident user status and healthcare use were captured in the Minimum Data Set (MDS) versus administrative data.

Methods

This retrospective observational cohort study was conducted on all NH residents (N = 8832) from Winnipeg, Manitoba, Canada, between April 1, 2011 and March 31, 2013. Six study measures exist. NH user status (newly admitted NH residents, those who transferred from one NH to another, and those who died) was measured using both MDS and administrative data. Rates of in-patient hospitalizations, emergency department (ED) visits without subsequent hospitalization, and physician examinations were also measured in each data source. We calculated the sensitivity, specificity, positive and negative predictive values (PPV, NPV), and overall agreement (kappa, κ) of each measure as captured by MDS using administrative data as the reference source. Also for each measure, logistic regression tested if the level of disagreement between data systems was associated with resident age and sex plus NH owner-operator status.

Results

MDS accurately identified newly admitted residents (κ = 0.97), those who transferred between NHs (κ = 0.90), and those who died (κ = 0.95). Measures of healthcare use were captured less accurately by MDS, with high levels of both under-reporting and false positives (e.g., for in-patient hospitalizations sensitivity = 0.58, PPV = 0.45), and moderate overall agreement levels (e.g., κ = 0.39 for ED visits). Disagreement was sometimes greater for younger males, and for residents living in for-profit NHs.

Conclusions

MDS can be used as a stand-alone tool to accurately capture basic measures of NH use (admission, transfer, and death), and by proxy NH length of stay. As compared to administrative data, MDS does not accurately capture NH resident healthcare use. Research investigating these and other healthcare transitions by NH residents requires a combination of the MDS and administrative data systems.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3089-7) contains supplementary material, which is available to authorized users.

A before-after study of hospital use in two frail populations receiving different home-based services over the same time in Vancouver, Canada

Background

As individuals age, they are more likely to experience increasing frailty and more frequent use of hospital services. First, we explored whether initiating home-based primary care in a frail homebound cohort, influenced hospital use. Second, we explored whether initiating regular home care support for personal care with usual primary care, in a second somewhat less frail cohort, influenced hospital use.

Methods

This was a before-after retrospective cohort study of two frail populations in Vancouver, Canada using administrative data to assess the influence of two different services started in two different cohorts over the same time period. The participants were 246 recipients of integrated home-based primary care and 492 recipients of home care followed between July 1st, 2008 and June 30th, 2013 before and after starting their respective services. Individuals in each group were linked to their hospital emergency department visit and discharge abstract records. The main outcome measures were mean emergency department visit and hospital admission rates per 1000 patient days for 21 months before versus the period after receipt of services, and the adjusted incidence rate ratios (IRRs) on these outcomes post receipt of service.

Results

Before versus after starting integrated home-based primary care, emergency department visit rates per 1000 patient days (95% confidence intervals) were 4.1 (3.8, 4.4) versus 3.7 (3.3, 4.1), and hospital admissions rates were 2.3 (2.1, 2.5) versus 2.2 (1.9, 2.5). Before versus after starting home care, emergency department visit rates per 1000 patient days (95% confidence intervals) were 3.0 (2.8, 3.2) versus 4.0 (3.7, 4.3) visits and hospital admissions rates were 1.3 (1.2, 1.4) versus 1.9 (1.7, 2.1). Home-based primary care IRRs were 0.91 (0.72, 1.15) and 0.99 (0.76, 1.27) and home care IRRs were 1.34 (1.15, 1.56) and 1.46 (1.22, 1.74) for emergency department visits and hospital admissions respectively.

Conclusions

After enrollment in integrated home-based primary care, emergency department visit and hospital admission rates stabilized. After starting home care with usual primary care, emergency department visit and hospital admission rates continued to rise.

Barriers to ethical nursing practice for older adults in long-term care facilities

AIMS AND OBJECTIVES

To explore barriers to ethical nursing practice for older adults in long-term care facilities from the perspectives of nurses in South Korea.

BACKGROUND

The number of older adults admitted to long-term care facilities is increasing rapidly in South Korea. To provide this population with quality care, a solid moral foundation should be emphasised to ensure the provision of ethical nursing practices. Barriers to implementing an ethical nursing practice for older adults in long-term care facilities have not been fully explored in previous literature.

DESIGN

A qualitative, descriptive design was used to explore barriers to ethical nursing practice as perceived by registered nurses in long-term care facilities in South Korea.

METHODS

Individual interviews were conducted with 17 registered nurses recruited using purposive (snowball) sampling who care for older adults in long-term care facilities in South Korea. Data were analysed using qualitative content analysis.

RESULTS

Five main themes emerged from the data analysis concerning barriers to the ethical nursing practice of long-term care facilities: emotional distress, treatments restricting freedom of physical activities, difficulty coping with emergencies, difficulty communicating with the older adult patients and friction between nurses and nursing assistants.

CONCLUSIONS

This study has identified methods that could be used to improve ethical nursing practices for older adults in long-term care facilities. Because it is difficult to improve the quality of care through education and staffing alone, other factors may also require attention.

RELEVANCE FOR CLINICAL PRACTICE

Support programmes and educational opportunities are needed for nurses who experience emotional distress and lack of competency to strengthen their resilience towards some of the negative aspects of care and being a nurse that were identified in this study.

Clinical Complexity and Use of Antipsychotics and Restraints in Long-Term Care Residents with Parkinson's Disease

BACKGROUND

Patients with Parkinson's disease (PD) and/or Parkinsonism are affected by a complex burden of comorbidity. Many ultimately require institutional care, where they may be subject to the application of physical restraints or the prescription of antipsychotic medications, making them more vulnerable to adverse outcomes.

OBJECTIVES

The objectives of this paper are to: 1) describe the clinical complexity of older institutionalized persons with PD; and 2) examine patterns and predictors of restraint use and prescription of antipsychotics in this population.

METHODS

Population-based cross-sectional cohort study. Residents with PD and/or Parkinsonism living in long-term care (LTC) facilities in 6 Canadian provinces and 1 Northern Territory and Complex Continuing Care (CCC) facilities in Manitoba and Ontario, Canada. The RAI MDS 2.0 instrument was used to assess all LTC residents and CCC residents. Clinical characteristics and the prevalence of major comorbidities were examined. Multivariate modeling was used to identify the characteristics of PD residents most associated with the prescription of antipsychotics and the use of restraints in LTC and CCC facilities.

RESULTS

Residents with PD in LTC and CCC exhibit a high prevalence of dementia, major psychiatric disorders, stroke, heart failure, chronic obstructive pulmonary disease and diabetes mellitus. More than 90% of LTC and CCC residents with PD had cognitive impairment; with more than half having moderate to severe impairment. Residents with PD were more likely to receive antipsychotics than those without PD. Antipsychotic use was associated with psychosis and aggressive behaviours, but also with unsteady gait and higher comorbidity and medication count. Similarly, although more common in CCC than LTC facilities, both psychosis and aggressive behaviours were associated with restraint use, as was greater cognitive and functional impairment, and urinary incontinence. Younger age, male gender, and lower physician access were all associated with greater antipsychotic and restraint use.

CONCLUSIONS

LTC and CCC residents with PD are very complex medically. Use of antipsychotics and restraints is common, and their use is often associated with factors other than psychosis or aggression.

Development, validation and testing of a nursing home to emergency room transfer checklist

AIMS AND OBJECTIVES

To develop and test the feasibility of an instrument to support patients' nursing home to emergency room transfer.

BACKGROUND

Transfers from a nursing home care facility to an acute care facility such as a hospital emergency room are common. However, the prevalence of an information gap for transferring residents' health data to acute care facility is high. An evidence-based transfer instrument, which could fill this gap, is lacking.

DESIGN

Development of a nursing home to emergency room transfer checklist, validation of items using the Delphi method and testing the feasibility and benefits of using the nursing home to emergency room transfer checklist.

METHODS

Items were developed based on qualitative data from previous research. Delphi validation, retrospective chart review (baseline data) and a 6-month prospective study design were applied to test the feasibility of using the checklist. Variables for testing the feasibility of the checklist included residents' 30-day readmission rate and length of hospital stay.

RESULTS

Development of the nursing home to emergency room transfer checklist resulted in four main parts: (i) demographic data of the nursing home resident; (ii) critical data for nursing home to emergency room transfer; (iii) contact information and (iv) critical data for emergency room to nursing home transfer. Two rounds of Delphi validation resulted in a mean score (standard deviation) ranging from 4.39 (1.13)-4.98 (.15). Time required to complete the checklist was 3-5 min. Use of the nursing home to emergency room transfer checklist resulted in a 30-day readmission rate of 13.4%, which was lower than the baseline rate of 15.9%.

CONCLUSIONS

The nursing home to emergency room transfer checklist was developed for transferring nursing home residents to an emergency room. The instrument was found to be an effective tool for this process.

RELEVANCE TO CLINICAL PRACTICE

Use of the nursing home to emergency room transfer checklist for nursing home transfers could fill the information gap that exists when transferring older adults between facilities such as nursing homes and hospitals.

Influences on the start, selection and duration of treatment with antibiotics in long-term care facilities

BACKGROUND

Understanding the extent to which current antibiotic prescribing behaviour is influenced by clinicians' historical patterns of practice will help target interventions to optimize antibiotic use in long-term care. Our objective was to evaluate whether clinicians' historical prescribing behaviours influence the start, prolongation and class selection for treatment with antibiotics in residents of long-term care facilities.

METHODS

We conducted a retrospective cohort study of all physicians who prescribed to residents in long-term care facilities in Ontario between Jan. 1 and Dec. 31, 2014. We examined variability in antibiotic prescribing among physicians for 3 measures: start of treatment with antibiotics, use of prolonged durations exceeding 7 days and selection of fluoroquinolones. Funnel plots with control limits were used to determine the extent of variation and characterize physicians as extreme low, low, average, high and extreme high prescribers for each tendency. Multivariable logistic regression was used to assess whether a clinician's prescribing tendency in the previous year predicted current prescribing patterns, after accounting for residents' demographics, comorbidity, functional status and indwelling devices.

RESULTS

Among 1695 long-term care physicians, who prescribed for 93 132 residents, there was wide variability in the start of antibiotic treatment (median 45% of patients, interquartile range [IQR] 32%-55%), use of prolonged treatment durations (median 30% of antibiotic prescriptions, IQR 19%-46%) and selection of fluoroquinolones (median 27% of antibiotic prescriptions, IQR 18%-37%). Prescribing tendencies for antibiotics by physicians in 2014 correlated strongly with tendencies in the previous year. After controlling for individual resident characteristics, prior prescribing tendency was a significant predictor of current practice.

INTERPRETATION

Physicians prescribing antibiotics exhibited individual, measurable and historical tendencies toward start of antibiotic treatment, use of prolonged treatment duration and class selection. Prescriber audit and feedback may be a promising tool to optimize antibiotic use in long-term care facilities.

Enhancing Knowledge and InterProfessional care for Heart Failure (EKWIP-HF) in long-term care: a pilot study

Background

Heart failure (HF) affects 20% of long-term care (LTC) residents and is associated with significant morbidity, acute care visits, and mortality. Barriers to HF management are staff knowledge gaps and ineffective interprofessional (IP) communication. This pilot study assessed the acceptability, feasibility, and impact of an intervention to (1) improve HF knowledge; (2) improve IP communication; and (3) integrate improved knowledge and communication processes into work routines.

Methods

The intervention provides multimodal IP education about HF in LTC, including specialist-supported bedside teaching. It was piloted on single units in two facilities. A mixed-methods repeated-measures approach was used to collect qualitative and quantitative process and outcome data at baseline and 6 months post-intervention.

Results

Results were similar at both sites. Participants developed optimized IP communication to promote HF care. Results indicate a perceived increase in staff confidence and self-efficacy, strengthened assessment and clinical proficiency skills, and more effective IP collaboration. Staff deemed the intervention useful and feasible.

Conclusions

This pilot study suggests that a novel intervention in which HF-specific knowledge is applied by LTC staff to improve IP collaboration in their own work place is acceptable and feasible and has a favourable preliminary impact on staff knowledge and IP communication.