Factors predisposing nursing home resident to inappropriate transfer to emergency department. The FINE study protocol

Cost of care pathways before and after appropriate and inappropriate transfers to the emergency department among nursing home residents: results from the FINE study

BACKGROUND

Transfers of nursing home (NH) residents to the emergency department (ED) is frequent. Our main objective was to assess the cost of care pathways 6 months before and after the transfer to the emergency department among NH residents, according to the type of transfer (i.e. appropriate or inappropriate).

METHODS

This was a part of an observational, multicenter, case-control study: the Factors associated with INappropriate transfer to the Emergency department among nursing home residents (FINE) study. Sixteen public hospitals of the former Midi-Pyrénées region participated in recruitment, in 2016. During the inclusion period, all NH residents arriving at the ED were included. A pluri-disciplinary team categorized each transfer to the ED into 2 groups: appropriate or inappropriate. Direct medical and nonmedical costs were assessed from the French Health Insurance (FHI) perspective. Healthcare resources were retrospectively gathered from the FHI database and valued using the tariffs reimbursed by the FHI. Costs were recorded over a 6-month period before and after transfer to the ED. Other variables were used for analysis: sex, age, Charlson score, season, death and presence inside the NH of a coordinating physician or a geriatric nursing assistant.

RESULTS

Among the 1037 patients initially included in the FINE study, 616 who were listed in the FHI database were included in this economic study. Among them, 132 (21.4%) had an inappropriate transfer to the ED. In the 6 months before ED transfer, total direct costs on average amounted to 8,145€ vs. 6,493€ in the inappropriate and appropriate transfer groups, respectively. In the 6 months after ED transfer, they amounted on average to 9,050€ vs. 12,094€.

CONCLUSIONS

Total costs on average are higher after transfer to the ED, but there is no significant increase in healthcare expenditure with inappropriate ED transfer. Support for NH staff and better pathways of care could be necessary to reduce healthcare expenditures in NH residents.

TRIAL REGISTRATION

clinicaltrials.gov, NCT02677272.

Exploring Predictive Factors for Potentially Avoidable Emergency Department Transfers: Findings From the FINE Study

OBJECTIVES

To assess the prevalence of potentially avoidable transfers (PAT) and identify factors associated with these transfers to emergency departments (EDs) among nursing home (NH) residents.

DESIGN

This is a secondary outcome analysis of the FINE study, a multicenter observational study collecting data on NH residents, NH settings, and contextual factors of ED transfers.

SETTINGS AND PARTICIPANTS

NHs in the former Midi-Pyrénées region of the southwest of France (n = 312); a total of 1037 NH residents who experienced ED transfers (n = 1017) between January 2016 and December 2016.

METHODS

The analysis included resident baseline characteristics and NH and transfer decision-making characteristics. An expert group categorized the transfer status as either PAT or unavoidable. Multivariable analysis using a mixed logistic model, accounting for intra-NH correlation, was conducted to assess factors independently associated with PAT.

RESULTS

Among 1017 included transfers, 87.02% (n = 885) were identified as PAT and 12.98% (n = 132) unavoidable transfers. Multivariable analysis revealed that the following patient-related factors were associated with a likely high rate of PAT: usual behavior disturbances before transfer, including productive trouble (OR 2.04, 95% CI 1.25-3.33; P = .0044) and unusual symptom of falling during the week preceding the transfer (OR 4.55, 95% CI 1.76-11.82; P = .0019). On the other hand, distance between ED and NH (OR 0.98, 95% CI 0.97-0.998; P = .0231), NH staff trained in palliative care in the last 3 years (OR 0.52, 95% CI 0.29-0.95; P = .0324), the impossibility of direct hospitalization to an appropriate unit (OR 0.54, 95% CI 0.34-0.87; P = .0117), and the resident Charlson Comorbidity Index (OR 0.90, 95% CI 0.82-0.99; P = .0369) were associated with a lower probability of PAT.

CONCLUSION AND IMPLICATIONS

Transfers from NHs to hospital EDs were frequently potentially avoidable, meaning that there are still significant opportunities to reduce PAT. Our findings may help to specifically identify interventions that should be targeted at both NH and resident levels.

Emergency department admissions and economic costs burden related to ambulatory care sensitive conditions in older adults living in care homes

OBJECTIVES

To assess the frequency of emergency department admissions (EDA) for ambulatory care sensitive conditions (ACSC) and non-ACSC among older adults living in care homes (CH), to describe and compare their demographic and clinical characteristics, the outcomes of the hospitalisation process and the associated costs.

METHOD

This multicenter, retrospective and observational study evaluated 2444 EDAs of older adults ≥ 65 years old living in care homes in 5 emergency departments in Catalonia (Spain) by ACSC and non-ACSC, in 2017. Sociodemographic variables, prior functional and cognitive status, and information on diagnosis and hospitalisation were collected. Additionally, the costs related with the EDAs were calculated, as well as a sensitivity analysis using different assumptions of decreased admissions due to ACSC.

RESULTS

A total of 2444 ED admissions were analysed. The patients' mean (SD) age was 85.9 (7.2) years. The frequency of ACSC-EDA and non-ACSC-EDA was 56.6% and 43.4%, respectively. Severe dependency and cognitive impairment were present in 56.6% and 78%, respectively, with no differences between the two groups. The three most frequent ACSC were falls/trauma (13.8%), chronic obstructive pulmonary disease/asthma (11.4%) and urinary tract infection (7.4%). The average cost per ACSC-EDA was є1,408.24. Assuming a 60% reduction of ACSC-EDA, the estimated cost savings would be є1.2 million.

CONCLUSIONS

Emergency admissions for ACSC from care homes have a significant impact on both frequency and costs. Reducing these conditions through targeted interventions could redirect the avoided costs towards improving care support in residential settings.

Acute Health Care Provision in Rural Long-Term Care Facilities: A Scoping Review of Integrated Care Models

OBJECTIVES

We aimed to map integrated care models for acute health care in rural long-term care facilities (LTCFs) for future investigation.

DESIGN

Systematic scoping review.

SETTING AND PARTICIPANTS

Residential LTCFs in rural areas worldwide.

METHODS

The common health-related online databases were systematically searched complemented by a manual search of gray literature. Following the 5-stage framework of Arksey and O'Malley, the extent of included literature was identified and findings were summarized using qualitative meta-summary.

RESULTS

A total of 35 references were included for synthesis, predominantly primary research on completed and ongoing projects reporting on integrated health care services in rural LTCFs. Incorporating previous research, we extracted 5 approaches of integrated acute-health care models: (1) Availability of Specialists, (2) Networks, (3) Quality Management (QM) and Organization, (4) Telemedicine, and (5) Telehealth.

CONCLUSIONS AND IMPLICATIONS

This research presents the result of a literature review examining integrated care models as a way to improve acute health care in LTCFs in rural areas. Integrated care models in rural settings can help face the challenging situation and fulfil the complex health care needs of LTCF residents by reducing fragmentation and thereby improve continuity and coordination of acute health care services. These results can guide policy making in creating interventions and support adequate implementation of care models by knowledge translation in health care.

Pneumonia-associated Emergency Transfers, Functional Decline, and Mortality in Nursing Home Residents

OBJECTIVE

To describe nursing home residents (NHRs) transferred to the emergency department (ED) with pneumonia, and investigate the association of pneumonia with functional ability and mortality.

DESIGN

Case-control observational multicenter study.

SETTING AND PARTICIPANTS

Participants of the FINE study, including 1037 NHRs presenting to 17 EDs in France over 4 nonconsecutive weeks (1 per season) in 2016, mean age 87.2 years ± 7.1, 68.4% women.

METHODS

Activities of daily living (ADL) performance evolution between (1) 15 days before transfer and (2) within 7 days after discharge back to the nursing home was compared in NHRs with or without pneumonia. The association of pneumonia with functional evolution was investigated by a mixed-effect linear regression of ADL and mortality was compared by a χ² test.

RESULTS

NHRs with pneumonia (n = 232; 22.4%) were more likely to have a lower ADL performance than NHRs without pneumonia (n = 805, 77.6%). They presented with a more severe clinical condition, were more likely to be hospitalized after ED and to stay longer in ED and in hospital. They showed a 0.5 decline in median ADL performance after transfer and a significantly higher mortality than NHRs without pneumonia (24.1% and 8.7%, respectively). Post-ED functional evolution did not differ significantly between NHRs with or without pneumonia.

CONCLUSIONS AND IMPLICATIONS

Pneumonia-associated ED transfers resulted in longer care pathways and higher mortality, but no significant difference in functional decline. This study identified a suggestive course of symptoms that could facilitate early identification of NHRs developing pneumonia and early management to prevent ED transfer.

Transferring nursing home residents to emergency departments by emergency physician-staffed emergency medical services: missed opportunities to avoid inappropriate care?

BACKGROUND

The decision to transfer a nursing home (NH) resident to an emergency department (ED) is multifactorial and challenging but many of the emergency physician-staffed emergency medical service (EP-EMS) interventions and ED transfers are probably inappropriate.

METHODS

We conducted a retrospective, cross-sectional study in three EP-EMSs in Belgium over a period of three years. We registered indicators that are potentially associated with inappropriate transfers: patient characteristics, availability of written do not resuscitate (DNR) orders or treatment restrictions, involvement of a general practitioner (GP) and availability of transfer notes. We also explored the association between age, the Charlson Comordity Index (CCI), polypharmacy, dementia, and the availability of DNR documents.

RESULTS

We registered 308 EP-EMS interventions in NH residents. In 98% the caller was a health-care professional. In 75% there was no GP present and 40% had no transfer note. Thirty-two percentage of the patients had dementia, 45% had more than two comorbidities and 68% took five medications or more. In 6% cardiopulmonary resuscitation was performed. DNR orders were available in 25%. Eighty-eight percentage of the NH residents were transferred to the ED. Forty-four percent had a CCI >5. In patients of ≥90 years, with a CCI >5, with dementia and with polypharmacy, DNR orders were not available in 81%, 67%%,and 69%, respectively.

CONCLUSIONS

Improved EMS dispatch centre-NH caller interaction, more involvement of GP's, higher availability of DNR orders and better communication between GPs/NHs and EP-EMS could prevent inappropriate interventions, futile prehospital aactions,and ED transfers.

Factors associated with Emergency Medical Dispatcher request and residents' inappropriate transfers from Nursing Homes to Emergency Department

PURPOSE

In the last decades, the amount of emergency department (ED) transfers of nursing home (NH) residents has disproportionally increased in western countries. The main role of emergency medical dispatcher (EMD) among this population is to refer residents to EDs in the most appropriate way. The aim of this study was to assess risk factors of inappropriate transfers from NH to ED after EMD request.

METHODS

This research was a secondary analysis of a prospective observational multicenter study carried out in 17 EDs entitled FINE aimed to assess potentially inappropriate transfer prevalence among this population. Inappropriate transfers were determined in the FINE study threw a standardized approach by a unique expert team.

RESULTS

Overall, 572/1037 (55.2%) of residents were transferred to the ED after an EMD's decision. Among them, 92/572 (16.1%) transfers was defined as inappropriate. The average age was 87.3 years old (SD = 0.3). The main reason for ED transfer were falls (217/572, 37.9%). In multivariate analysis, the presence of a Special Care Unit in NH was significantly associated with a high rate of inappropriate transfer (OR 1.78; 95 CI [1.07-2.93]; p = 0.02) whereas a medical examination by a general practitioner before the transfer (OR 0.55; 95 CI [0.33-0.83]; p = 0.02) and a prompt access to psychiatric advice (OR 0.54; 95 CI [0.33-0.84]; p = 0.007) were associated with a low rate of potentially inappropriate transfer.

CONCLUSION

Promoting onsite medical assessment and partnership thanks to available geriatrician's advice may help the emergency medical dispatcher to improve the appropriateness of residents' transfer from Nursing Home to the emergency department.

Does an Integrated Palliative Care Program Reduce Emergency Department Transfers for Nursing Home Palliative Residents?

Background: Nursing homes (NHs) are faced with a myriad of challenges to provide quality palliative care to residents who are at their end of life. Objectives: To describe and examine the impact of the GeriCare Palliative Care Program, which comprises telemedicine, on-site clinical preceptorship, palliative care education program, and Advance Care Planning (ACP) advocacy in reducing emergency department (ED) transfers from NHs. Design: Retrospective cohort study. Setting/Subjects: A total of 217 telemedicine consults were conducted for 187 unique NH residents across 5 NHs in Singapore over a 27-month period from April 2018 to June 2020. Measurement: Records of all enrolled palliative care residents who were triaged by telemedicine consultations were examined. Results: Our findings revealed that 82% of our urgent telemedicine consultations have successfully averted ED transfers. Gender and completion of ACP were statistically significant between ED transfer group and non-ED transfer group. Among those who completed their ACP, 78.3% of the ED transfer group chose limited intervention as their main goals of care compared with 30% in the non-ED transfer group. Conclusions: The GeriCare Palliative Care Program is a novel program, which is developed to improve the quality of palliative care in NHs. The comprehensive GeriCare model comprises a systematic framework, an integration of clinical support, ACP advocacy, and education program. Our findings demonstrated that these interventions synergistically led to a reduction in ED transfers while optimizing the residents' quality of care. By carrying out the targeted initiatives to support NHs, the residents could age-in-place comfortably.

Factors Associated with Potentially Inappropriate Transfer to the Emergency Department among Nursing Home Residents

OBJECTIVES

To determine the factors associated with the potentially inappropriate transfer of nursing home (NH) residents to emergency departments (EDs) and to compare hospitalization costs before and after transfer of individuals addressed inappropriately vs those addressed appropriately.

DESIGN

Multicenter, observational, case-control study.

SETTING AND PARTICIPANTS

17 hospitals in France, 1037 NH residents.

MEASURES

All NH residents transferred to the 17 public hospitals' EDs in southern France were systematically included for 1 week per season. An expert panel composed of family physicians, emergency physicians, geriatricians, and pharmacists defined whether the transfer was potentially inappropriate or appropriate. Residents' and NHs' characteristics and contextual factors were entered into a mixed logistic regression to determine factors associated independently with potentially inappropriate transfers. Hospital costs were collected in the national health insurance claims database for the 6 months before and after the transfer.

RESULTS

A total of 1037 NH residents (mean age 87.2 ± 7.1, 68% female) were transferred to the ED; 220 (21%) transfers were considered potentially inappropriate. After adjustment, anorexia [odds ratio (OR) 2.41, 95% confidence interval (CI) 1.57-3.71], high level of disability (OR 0.90, 95% CI 0.81-0.99), and inability to receive prompt medical advice (OR 1.67, 95% CI 1.20-2.32) were significantly associated with increased likelihood of potentially inappropriate transfers. The existence of an Alzheimer's disease special care unit in the NH (OR 0.66, 95% CI 0.48-0.92), NH staff trained on advance directives (OR 0.61, 95% CI 0.41-0.89), and calling the SAMU (mobile emergency medical unit) (OR 0.47, 95% CI 0.34-0.66) were significantly associated with a lower probability of potentially inappropriate transfer. Although the 6-month hospitalization costs prior to transfer were higher among potentially inappropriate transfers compared with appropriate transfers (€6694 and €4894, respectively), transfer appropriateness was not significantly associated with hospital costs.

CONCLUSIONS AND IMPLICATIONS

Transfers from NHs to hospital EDs were frequently appropriate. Transfer appropriateness was conditioned by NH staff training, access to specialists' medical advice, and calling the SAMU before making transfer decisions.

TRIAL REGISTRATION

clinicaltrials.gov, NCT02677272.

Trajectories of Symptoms in Nursing Home Residents after a Transfer to the Emergency Department

OBJECTIVE

To describe the trajectories of pain, dyspnea, fever, confusion, agitation and fatigue of nursing home residents' (NHRs) after a transfer to the emergency department (ED).

DESIGN

Observational multicenter study.

SETTING

17 EDs in France.

PARTICIPANTS

751 NHRs presenting to EDs over four non-consecutive weeks (one week per season) in 2016.

MEASUREMENTS

Trajectories of symptoms (binary variables) including pain, dyspnea, fever, agitation, confusion and fatigue at four times: before ED transfer, during the transfer, in the ED and after discharge.

RESULTS

Group-based multi-trajectory modelling was performed to identify groups of NHRs following similar trajectories of symptoms evolution after a transfer to ED. Five groups were identified. In group 1 (n=190), NHRs presented with confusion and a rising prevalence of fatigue. In group 2 (n=212), NHRs presented with a highly prevalent but declining pain. In group 3 (n=158), NHRs presented with similar peaking pain prevalence, rising confusion and fatigue, and a high but stable agitation prevalence. In group 4 (n=144), NHRs presented with a highly prevalent but declining dyspnea, rising then declining fever, rising confusion, and a high and fluctuating fatigue prevalence. In group 5 (n=47), NHRs presented with a highly prevalent but declining fever, rising then declining dyspnea, stable and high both fatigue and pain prevalence, stable and low prevalence of confusion.

CONCLUSION

Symptom alleviation in NHRs transferred to ED was better achieved in those with pain, fever or dyspnea rather than in those with confusion, agitation and fatigue. NHRs' resilience through the stress of an ED transfer could be predicted by comorbidity and functional abilities, challenged by acute conditions representing various levels of stress intensity, and evaluated on the course of non-specific symptoms. NHRs' resilience is key to estimate the appropriateness of an ED transfer and should facilitate advance care planning regarding NHRs' hospitalizations.

Cutaneous impact location: a new tool to predict intracranial lesion among the elderly with mild traumatic brain injury?

Background

Mild traumatic brain injury is the leading cause of arrivals to emergency department due to trauma in the 65-year-old population and over. Recent studies conducted in ED suggested a low intracranial lesion prevalence. The objectives of this study were to assess the prevalence and risk factors of intracranial lesion in older patients admitted to emergency department for mild traumatic brain injury by reporting in the emergency department the precise anamnesis of injury and clinical findings.

Methods

Patients of 65 years old and over admitted in emergency department were prospectively included in this monocentric study. The primary outcome was the prevalence of intracranial lesion threw neuroimaging.

Results

Between January and June 2019, 365 patients were included and 66.8% were women. Mean age was 86.5 years old (SD = 8.5). Ground-level fall was the most common cause of mild traumatic brain injury and occurred in 335 patients (91.8%). Overall, 26 out of 365 (7.2%) patients had an intracranial lesion. Compared with cutaneous frontal impact (medium risk group), the relative risk of intracranial lesion was 2.54 (95% CI 1.20 to 5.42) for patients with temporoparietal or occipital impact (high risk group) and 0.12 (95% CI 0.01 to 0.93) for patients with facial impact or no cutaneous impact (low risk group). There was not statistical increase in risk of intracranial injury with patients receiving antiplatelets (RR = 1.43; 95% CI 0.68 to 2.99) or anticoagulants (RR = 0.98; 95% CI 0.45 to 2.14).

Conclusion

Among patients of 65 years old and over, the prevalence of intracranial lesion after a mild traumatic brain injury was similar to the younger adult population. The cutaneous impact location on clinical examination at the emergency department may identify older patients with low, medium and high risk for intracranial lesion.

Nursing Home Residents' Functional Trajectories and Mortality After a Transfer to the Emergency Department

OBJECTIVE

To describe nursing home residents' (NHRs) functional trajectories and mortality after a transfer to the emergency department (ED).

DESIGN

Case-control observational multicenter study.

SETTING AND PARTICIPANTS

In total, 1037 NHRs presenting to 17 EDs in France over 4 nonconsecutive weeks in 2016.

METHODS

Finite mixture models were fitted to longitudinal data on activities of daily living (ADL) scores before transfer (time 1), during hospitalization (time 2), and within 1 week after discharge (time 3) to identify groups of NHRs following similar functional evolution. Factors associated with mortality were investigated by Cox regressions.

RESULTS

Trajectory modeling identified 4 distinct trajectories of ADL. The first showed a high and stable (across time 1, time 2, and time 3) functional capacity around 5.2/6 ADL points, with breathlessness as the main condition leading to transfer. The second displayed an initial 37.8% decrease in baseline ADL performance (between time 1 and time 2), followed by a 12.5% recovery of baseline ADL performance (time 2‒time 3), with fractures as the main condition. The third displayed a similar initial decrease, followed by a 6.7% recovery. The fourth displayed an initial 70.1% decrease, followed by an 8.5% recover, with more complex geriatric polypathology situations. Functional decline was more likely after being transferred for a cerebrovascular condition or for a fracture, after being discharged from ED to a surgery department, and with a heavier burden of distressing symptoms during transfer. Mortality after ED transfer was more likely in older NHRs, those in a more severe condition, those who were hospitalized more frequently in the past month, and those transferred for cerebrovascular conditions or breathlessness.

CONCLUSIONS AND IMPLICATIONS

Identified trajectories and factors associated with functional decline and mortality should help clinicians decide whether to transfer NHRs to ED. NHRs with high functional ability seem to benefit from ED transfers whereas on-site alternatives should be sought for those with poor functional ability.

Acute health care services use among nursing home residents in Germany: a comparative analysis of out-of-hours medical care, emergency department visits and acute hospital admissions

BACKGROUND

Nursing home (NH) residents often utilise acute health care services. However, comparative data on those are lacking.

AIMS

Investigating German NH residents' use of out-of-hours medical care (OOHC), visits to emergency departments (EDs) and acute hospital admissions (AHAs).

METHODS

Using claims data of 1665 residents for 2014-2015, we conducted a retrospective cohort study, examining the incidence rates involving the different services. Multivariate Poisson regression analyses were performed to calculate relative risks (RRs). Differences in the utilisations over the days of the week and of the reasons for contacts were assessed.

RESULTS

In total, 3576 contacts occurred (mean age 80.5 years, women 66.3%), resulting in an overall incidence rate of 2.7 per person-year (95% confidence interval 2.6-2.8). Strongest predictors were polypharmacy (RR 1.79; 95% CI 1.50-2.12), followed by male sex and higher care dependency. Among the three services AHAs showed the highest rates. Injuries were the most common reasons for visiting EDs, whereas for OOHC use and AHAs, coded diagnoses covered a broader spectrum. Utilisation of the services on weekdays varied, particularly for OOHC.

DISCUSSION

Polypharmacy, a higher care dependency and male sex seem to play a role in predicting acute health care services. Considering the distribution of the diagnoses of all three types, certain patterns concerning the symptoms' acuity become apparent.

CONCLUSIONS

Our findings revealed high acute health care services use among NH residents in Germany and differences among the three available services. This information can be used to design studies for investigating the appropriateness of these contacts.