Emergency department use by nursing home residents

Impact of an acute geriatric outreach service to residential aged care facilities on hospital admissions

INTRODUCTION

Residential aged care facility (RACF) residents frequently present to the emergency department (ED) and are often admitted to hospital. Some presentations and admissions may be avoidable. In 2013, Bankstown-Lidcombe Hospital introduced a subacute geriatric outreach service (SGOS), which had little impact on reducing ED presentations. In 2015, Bankstown-Lidcombe Hospital introduced an acute geriatric outreach service (AGOS), a geriatrician-led team that assesses and treats acutely unwell patients in RACFs. We aim to determine whether the AGOS reduces the risk of hospital admission for RACF residents.

METHODS

Hospital admissions data from 2010 to 2019 were used to conduct an interrupted time series (ITS) analysis. AGOS activity data were also summarized.

RESULTS

The average number of admissions from RACF per month declined from 42.8 during the SGOS period to 27.1 during the AGOS period. The difference of 15.7 admissions from RACF per month was statistically significant (95% CI 12.1-19.2; P < .001). After the introduction of the AGOS, the risk of admission to our geriatric department from RACFs was reduced by 36.1% (incidence rate ratio =0.64; 95% CI: 0.58-0.71; P < .001) compared to the SGOS period, adjusting for seasonality.

DISCUSSION

The AGOS probably reduced the risk of hospital admission for RACF residents.

Reducing preventable patient transfers from long-term care facilities to emergency departments: a scoping review

BACKGROUND

In Canada, there were over 60,000 long-term care facility patient transfers to emergency departments (EDs) in 2014, with up to a quarter of them being potentially preventable. Each preventable transfer exposes the patient to transport- and hospital-related complications, contributes to ED crowding, and adds significant costs to the health care system. There have been many proposed and studied interventions aimed at alleviating the issue, but few attempts to assess and evaluate different interventions across institutions.

METHODS

A systematic search of MEDLINE, CINAHL, and EMBASE for studies describing the impact of interventions aimed at reducing preventable transfers from long-term care facilities to EDs on ED transfer rate. Two independent reviewers screened the studies for inclusion and completed a quality assessment. A tabular and narrative synthesis was then completed. This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines.

RESULTS

A total of 26 studies were included (Cohen's k = 0.68). One was of low quality (Cohen's k = 0.58). Studies were summarized into five themes based on intervention type: Telemedicine, Outreach Teams, Interdisciplinary Care, Integrated Approaches, and Other. Effective interventions reported reductions in ED transfer rates post intervention ranging from 10 to 70%. Interdisciplinary health care teams staffed within long-term care facilities were the most effective interventions.

CONCLUSION

There are several promising interventions that have successfully reduced the number of preventable transfers from long-term care facilities to EDs in a variety of health care settings. Widespread implementation of these interventions has the potential to reduce ED crowding in Canada.

Improving the Efficiency of an Emergency Department Based on Activity-Relationship Diagram and Radio Frequency Identification Technology

Emergency department crowding has been one of the main issues in the health system in Taiwan. Previous studies have usually targeted the process improvement of patient treatment flow due to the difficulty of collecting Emergency Department (ED) staff data. In this study, we have proposed a hybrid model with Discrete Event Simulation, radio frequency identification applications, and activity-relationship diagrams to simulate the nurse movement flows and identify the relationship between different treatment sections. We used the results to formulate four facility layouts. Through comparing four scenarios, the simulation results indicated that 2.2 km of traveling distance or 140 min of traveling time reduction per nurse could be achieved from the best scenario.

Cost analysis of an integrated aged care program for residential aged care facilities

Objective To compare annual costs of an intervention for acutely unwell older residents in residential age care facilities (RACFs) with usual care. The intervention, the Aged Care Emergency (ACE) program, includes telephone clinical support aimed to reduce avoidable emergency department (ED) presentations by RACF residents. Methods This costing of the ACE intervention examines the perspective of service providers: RACFs, Hunter Medicare Local, the Ambulance Service of New South Wales, and EDs in the Hunter New England Local Health District. ACE was implemented in 69 RACFs in the Hunter region of NSW, Australia. Analysis used 14 weeks of ACE and ED service data (June–September 2014). The main outcome measure was the net cost and saving from ACE compared with usual care. It is based on the opportunity cost of implementing ACE and the opportunity savings of ED presentations avoided. Results Our analysis estimated that 981 avoided ED presentations could be attributed to ACE annually. Compared with usual care, ACE saved an estimated A$921214. Conclusions The ACE service supported a reduction in avoidable ED presentations and ambulance transfers among RACF residents. It generated a cost saving to health service providers, allowing reallocation of healthcare resources. What is known about the topic? Residents from RACFs are at risk of further deterioration when admitted to hospital, with high rates of delirium, falls, and medication errors. For this cohort, some conditions can be managed in the RACF without hospital transfer. By addressing avoidable presentations to EDs there is an opportunity to improve ED efficiency as well as providing care that is consistent with the resident’s goals of care. RACFs generate some avoidable ED presentations for residents who may be more appropriately treated in situ. What does this paper add? Telephone triaging with nursing support and training is a means by which ED presentations from RACFs can be reduced. One of the consequences of this intervention is ‘cost avoided’, largely through savings on ambulance costs. What are the implications for practitioners? Unnecessary transfer from RACFs to ED can be avoided through a multicomponent program that includes telephone support with cost-saving implications for EDs and ambulance services.

The Impact of Incomplete Nursing Home Transfer Documentation on Emergency Department Care

OBJECTIVES

Emergency department (ED) clinicians rely on the accuracy of written communication when assessing needs of nursing home (NH) residents. This study aimed to review the completeness of NH transfer documentation according to expected core components, as guided by the INTERACT 4.0 quality improvement tool. We also describe the association between patient or facility characteristics and transfer documentation completeness, as well as establish whether information gaps in NH-ED transfer documentation were associated with hospital admission.

DESIGN

Retrospective study using 2 abstractors blinded to the study aims.

SETTING AND PARTICIPANTS

474 records from NH residents transferred to the 3 EDs of Rhode Island's largest health care system from September 2015 to September 2016.

MEASURES

NH-ED transfer documentation completeness was reviewed according to the expected core items of transfer documentation, guided by the INTERACT 4.0 quality improvement tool. We used multivariable linear regression with random effects to assess factors associated with NH-ED transfer documentation completion and logistic regression with random effects to assess the relation between information gaps and hospital admission.

RESULTS

Of the 474 NH-ED transfer visits, mean patient age was 76 years; 43% were male, 14% were nonwhite, and 34% had dementia. NH-ED transfer documents were present for 97% of visits, and an average 11.9 of 15 INTERACT core items were complete. Usual mental status and reason for transfer were absent for 75% of patients, whereas functional status was absent for 80%. The multivariable model showed that a higher Charlson Comorbidity Index score (coefficient 0.08, standard error 0.04, P = .03) was associated with more complete documentation. More complete documentation was associated with greater likelihood of hospital admission (adjusted odds ratio = 1.09, 95% confidence interval = 1.01-1.18).

CONCLUSIONS/IMPLICATIONS

Usual mental and functional status and the reason for transfer are often missing in NH-ED transfer documents and should be incorporated into standardized transfer forms.

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.

Transitions From Skilled Nursing Facility to Home: The Relationship of Early Outpatient Care to Hospital Readmission

BACKGROUND

Many adults are discharged to skilled nursing facilities (SNFs) prior to returning home from the hospital. Patient characteristics and factors that can help to prevent postdischarge adverse outcomes are poorly understood.

OBJECTIVE

To identify whether early post-SNF discharge care reduces likelihood of 30-day hospital readmissions.

DESIGN

Secondary data analysis using the Electronic Medical Record, Medicare, Medicaid and the Minimum Data Set.

PARTICIPANTS/SETTING

Older (age > 65 years), community-dwelling adults admitted to a safety net hospital in the Midwest for 3 or more nights and discharged home after an SNF stay (n = 1543).

MEASUREMENTS

The primary outcome was hospital readmission within 30 days of SNF discharge. The primary independent variables were either a home health visit or an outpatient provider visit within a week of SNF discharge.

RESULTS

Out of 8754 community-dwelling, hospitalized older adults, 3025 (34.6%) were discharged to an SNF, of whom 1543 (51.0%) returned home. Among the SNF to home group, a home health visit within a week of SNF discharge was associated with reduced hazard of 30-day hospital readmission [adjusted hazard ratio (aHR) 0.61, P < .001] but outpatient provider visits were not associated with reduced risk of hospital readmission (aHR = 0.67, P = .821).

CONCLUSION

For patients discharged from an SNF to home, the finding that a home health visit within a week of discharge is associated with reduced hazard of 30-day hospital readmissions suggests a potential avenue for intervention.

Transfer of nursing home residents to emergency departments: organizational differences between nursing homes with high vs. low transfer rates

AIM

To explore possible factors in the organization of nursing homes that could be related to differences in the rate of transfer of residents from nursing homes to emergency department.

DESIGN

Explorative.

METHOD

In a single municipality, qualitative and quantitative data were collected from documents and through semi-structured interviews with 11 RNs from five nursing homes identified as having the highest vs. six identified as having the lowest transfer rates to emergency department. Data were analysed by non-parametric tests and basic content analysis.

RESULTS

All nursing homes in the highest transfer rate group and one in the lowest transfer rate group were run by private for-profit providers. Compared with the low group, the high group had fewer updated advance care plans and the RNs interviewed had less work experience in care of older people and less training in care of persons with dementia. There was no difference in nursing home size or staff/resident ratio. The RNs described similar possibilities to provide palliative care, medical equipment and perceived medical support from GPs.

Age and sex differences in hospitalisation of nursing home residents: a systematic review

OBJECTIVES

Nursing home residents (NHRs) are frequently suffering from multimorbidity, functional and cognitive impairment, often leading to hospital admissions. Studies have found that male NHRs are more often hospitalised. The influence of age is inconclusive. We aimed to investigate the epidemiology of hospitalisations in NHRs, particularly focusing on age-specific and sex-specific differences.

DESIGN

A systematic review was performed in PubMed, CINAHL and Scopus. Quality of studies was assessed.

SETTING

Studies conducted in nursing homes were included.

PARTICIPANTS

Nursing home residents.

PRIMARY AND SECONDARY OUTCOMES

Outcome measures were the prevalence, incidence or duration of all-cause hospitalisation by age or sex.

RESULTS

We identified 21 studies, 13 were conducted in the USA. The proportion of residents being hospitalised ranged across studies from 6.8% to 45.7% for various time periods of follow-up. A total of 20 studies assessed the influence of sex and found that hospitalisations are more often in male NHRs. A total of 16 studies conducted multivariate analyses and the OR of hospitalisation for males was between 1.22 and 1.67. Overall, 18 studies assessed the influence of age. Some studies showed an increasing proportion of admissions with increasing age, but several studies also found decreasing hospitalisations above the age of about 80-85 years. 8 of 13 studies conducting multivariate analyses included age as a continuous variable. Only 1 study reported stratified analyses by age and sex. 2 studies investigating primary causes of hospitalisation stratified by sex found some differences in main diagnoses.

DISCUSSION

Male NHRs are more often hospitalised than females, but reasons for that are not well investigated. The influence of age is less clear, but there seems to be no clear linear relationship between age and the proportion being hospitalised. Further studies should investigate age and sex differences in frequencies and reasons for hospitalisation in NHRs.

Deriving a Model of the Necessity to Hospitalize Nursing Home Residents

Although often important to recover from acute medical problems and exacerbations of chronic illness, hospitalizations can be traumatic for nursing home residents and costly for payers. It is important that unnecessary hospitalizations are avoided wherever possible. The authors derived and validated a diagnosis-based model to estimate the clinical necessity of hospitalizing nursing home residents with common conditions using data from an expert panel survey. Model validation involved a linked minimum data set—hospitalization claims data set. The expert panel of 12 experienced geriatricians rated the necessity of hospitalization for 1,948 clinical scenarios containing diagnoses, cognitive and functional status, age, gender, and advance directives. Primary diagnoses with the highest average necessity scores were respiratory failure, acute myocardial infarction, hip fracture, and brain injury. The secondary diagnosis-primary diagnosis interaction with the greatest impact was gastrointestinal bleed on gastroenteritis. Poor cognitive function and presence of an advance directive lowered the risk of hospitalization.

Identifying Potentially Preventable Emergency Department Visits by Nursing Home Residents in the United States

OBJECTIVES

To identify and describe potentially preventable emergency department (ED) visits by nursing home (NH) residents in the United States. These visits are important because they are common, frequently lead to hospitalization, and can be associated with significant cost to the patient and the health care system.

DESIGN

Retrospective analysis of the 2005-2010 National Hospital Ambulatory Care Survey (NHAMCS), comparing ED visits by nursing home residents that did not lead to hospital admission (potentially preventable) with those that led to admission (less likely preventable).

SETTING

Nationally representative sample of US EDs; federal hospitals and hospitals with fewer than 6 beds were excluded.

PARTICIPANTS

Older (age ≥65 years) NH residents with an ED visit during this time period.

MEASUREMENTS

Patient demographics, ED visit information including testing performed, interventions (both procedures and medications) provided, and diagnoses treated.

RESULTS

Older NH residents accounted for 3857 of 208,956 ED visits during the time period of interest (1.8%). When weighted to be nationally representative, these represent 13.97 million ED visits, equivalent to 1.8 ED visits annually per NH resident in the United States. More than half of visits (53.5%) did not lead to hospital admission; of those discharged from the ED, 62.8% had normal vital signs on presentation and 18.9% did not have any diagnostic testing before ED discharge. Injuries were 1.78 times more likely to be discharged than admitted (44.8% versus 25.3%, respectively, P < .001), whereas infections were 2.06 times as likely to be admitted as discharged (22.9% versus 11.1%, respectively). Computed tomography (CT) scans were performed in 25.4% and 30.1% of older NH residents who were discharged from the ED and admitted to the hospital, respectively, and more than 70% of these were CTs of the head. NH residents received centrally acting, sedating medications before ED discharge in 9.4% of visits.

CONCLUSION

This nationally representative sample of older NH residents suggests ED visits for injury, those that are associated with normal triage vital signs, and those that are not associated with any diagnostic testing are potentially preventable. Those discharged from the ED often undergo important testing and receive medications that may alter their physical examination on return to the nursing facility, highlighting the need for seamless communication of the ED course to NHs.

A systematic review of outcomes following emergency transfer to hospital for residents of aged care facilities

BACKGROUND

residential aged care facility (RACF) resident numbers are increasing. Residents are frequently frail with substantial co-morbidity, functional and cognitive impairment with high susceptibility to acute illness. Despite living in facilities staffed by health professionals, a considerable proportion of residents are transferred to hospital for management of acute deteriorations in health. This model of emergency care may have unintended consequences for patients and the healthcare system. This review describes available evidence about the consequences of transfers from RACF to hospital.

METHODS

a comprehensive search of the peer-reviewed literature using four electronic databases. Inclusion criteria were participants lived in nursing homes, care homes or long-term care, aged at least 65 years, and studies reported outcomes of acute ED transfer or hospital admission. Findings were synthesized and key factors identified.

RESULTS

residents of RACF frequently presented severely unwell with multi-system disease. In-hospital complications included pressure ulcers and delirium, in 19 and 38% of residents, respectively; and up to 80% experienced potentially invasive interventions. Despite specialist emergency care, mortality was high with up to 34% dying in hospital. Furthermore, there was extensive use of healthcare resources with large proportions of residents undergoing emergency ambulance transport (up to 95%), and inpatient admission (up to 81%).

CONCLUSIONS

acute emergency department (ED) transfer is a considerable burden for residents of RACF. From available evidence, it is not clear if benefits of in-hospital emergency care outweigh potential adverse complications of transfer. Future research is needed to better understand patient-centred outcomes of transfer and to explore alternative models of emergency healthcare.

Emergency ambulance service involvement with residential care homes in the support of older people with dementia: an observational study

BACKGROUND

Older people resident in care homes have a limited life expectancy and approximately two-thirds have limited mental capacity. Despite initiatives to reduce unplanned hospital admissions for this population, little is known about the involvement of emergency services in supporting residents in these settings.

METHODS

This paper reports on a longitudinal study that tracked the involvement of emergency ambulance personnel in the support of older people with dementia, resident in care homes with no on-site nursing providing personal care only. 133 residents with dementia across 6 care homes in the East of England were tracked for a year. The paper examines the frequency and reasons for emergency ambulance call-outs, outcomes and factors associated with emergency ambulance service use.

RESULTS

56% of residents used ambulance services. Less than half (43%) of all call-outs resulted in an unscheduled admission to hospital. In addition to trauma following a following a fall in the home, results suggest that at least a reasonable proportion of ambulance contacts are for ambulatory care sensitive conditions. An emergency ambulance is not likely to be called for older rather than younger residents or for women more than men. Length of residence does not influence use of emergency ambulance services among older people with dementia. Contact with primary care services and admission route into the care home were both significantly associated with emergency ambulance service use. The odds of using emergency ambulance services for residents admitted from a relative's home were 90% lower than the odds of using emergency ambulance services for residents admitted from their own home.

CONCLUSIONS

Emergency service involvement with this vulnerable population merits further examination. Future research on emergency ambulance service use by older people with dementia in care homes, should account for important contextual factors, namely, presence or absence of on-site nursing, GP involvement, and access to residents' family, alongside resident health characteristics.

Emergency Department Visits and Resulting Hospitalizations by Elderly Nursing Home Residents, 2001–2008

This study examines emergency department (ED) visits by nursing home (NH) residents aged 65 and over, and factors associated with hospital admission from the ED visit using data from the 2001–2008 National Hospital Ambulatory Medical Care Survey. Cross-sectional analyses were conducted on patient characteristics, diagnosis, procedures received, and triage status. On average, elderly NH residents visited EDs at a rate of 123 visits per 100 institutionalized persons. Nearly 15% of all ED visits had ambulatory care sensitive condition diagnoses. Nearly half of these visits resulted in hospital admission; chronic obstructive pulmonary disease, congestive heart failure, kidney/urinary tract infection, and dehydration were associated with higher odds of admission. Previous studies suggested that adequate medical staffing and appropriate care in the NH could reduce ED visits and hospital admissions. Recent initiatives seek to reduce ED visits and hospitalizations by providing financial incentives to spur better coordination between NH and hospital.

Emergency department visits by nursing home residents in the United States

OBJECTIVES

To characterize emergency department (ED) use by nursing home residents in the United States.

DESIGN

Analysis of the National Hospital Ambulatory Medical Care Survey.

SETTING

U.S. EDs from 2005 to 2008.

PARTICIPANTS

Individuals visiting U.S. EDs stratified according to nursing home residency.

MEASUREMENTS

All ED visits by nursing home residents were identified. The demographic and clinical characteristics and ED resource utilization, length of stay, and outcomes of nursing home residents and nonresidents were compared.

RESULTS

During 2005 to 2008, nursing home residents accounted for 9,104,735 of 475,077,828 U.S. ED visits (1.9%; 95% confidence interval (CI) = 1.8-2.1%). The annualized number of ED visits by nursing home residents was 2,276,184. Most nursing home residents were older (mean age 76.7, 95% CI = 75.8-77.5), female (63.3%), and non-Hispanic white (74.8%). Nursing home residents were more likely to have been discharged from the hospital in the prior 7 days (adjusted odds ratio (aOR = 1.4, 95% CI = 1.1-1.9), to present with fever (aOR = 1.9, 95% CI = 1.5-2.4) or hypotension (systolic blood pressure ≤90 mmHg, aOR = 1.8, 95% CI = 1.5-2.2), and to receive diagnostic tests (OR = 1.9, 95% CI = 1.6-2.2), imaging (OR = 1.5, 95% CI = 1.3-1.7), or procedures (OR = 1.6, 95% CI = 1.4-1.7) in the ED. Almost half of nursing home residents visiting the ED were admitted to the hospital. Nursing home residents were more likely to be admitted to the hospital (aOR = 1.8, 95% CI = 1.6-2.0) and to die (aOR = 2.3, 95% CI = 1.6-3.3).

CONCLUSION

Nursing home residents account for more than 2.2 million ED visits annually in the United States. Nursing home residents have greater medical acuity and complexity. These observations highlight the national challenges of organizing and delivering ED care to nursing home residents in the United States.

Patterns of antimicrobial use for respiratory tract infections in older residents of long-term care facilities

OBJECTIVES

To describe patterns of antimicrobial use for respiratory tract infections (RTIs) in older residents of long-term care facilities (LTCFs).

DESIGN

Data from a prospective, randomized, controlled study of the effect of vitamin E supplementation on RTIs conducted from April 1998 through August 2001 were analyzed.

SETTING

Thirty-three LTCFs in the greater Boston area.

PARTICIPANTS

Six hundred seventeen subjects aged 65 and older residing in LTCFs.

MEASUREMENTS

RTIs, categorized as acute bronchitis, pneumonia, common cold, influenza-like illness, pharyngitis, and sinusitis, were studied for appropriateness of antimicrobial use, type of antibiotics used, and factors associated with their use. For cases in which drug treatment was administered, antibiotic use was rated as appropriate (when an effective drug was used), inappropriate (when a more-effective drug was indicated), or unjustified (when use of any antimicrobial was not indicated).

RESULTS

Of 752 documented episodes of RTI, overall treatment was appropriate in 79% of episodes, inappropriate in 2%, and unjustified in 19%. For acute bronchitis, treatment was appropriate in 35% and unjustified in 65% of cases. For pneumonia, treatment was appropriate in 87% of episodes. Of the most commonly used antimicrobials, macrolide use was unjustified in 43% of cases. No statistically significant differences in the patterns of antibiotic use were observed when stratified according to age, sex, race, or comorbid conditions, including diabetes mellitus, dementia, and chronic kidney disease.

CONCLUSION

Antimicrobials were unjustifiably used for one-fifth of RTIs and more than two-thirds of cases of acute bronchitis, suggesting a need for programs to improve antibiotic prescribing at LTCFs.

Nursing home revenue source and information availability during the emergency department evaluation of nursing home residents

OBJECTIVES

Lack of access to medical information for nursing home residents during emergency department (ED) evaluation is a barrier to quality care. We hypothesized that the quantity of information available in the ED differs based on the funding source of the resident's nursing home.

DESIGN

Cross-sectional observational study.

SETTING

Single academic ED.

PARTICIPANTS

Participants were 128 skilled nursing facility (SNF) residents age 65 or older from 12 SNFs.

MEASUREMENTS

Emergency physicians documented knowledge of 9 essential information items. SNFs were categorized as accepting or not accepting Medicaid.

RESULTS

Questionnaires were completed for 128 patients, of whom 95 (74%) were from 1 of 8 Medicaid-funded SNFs and 33 (26%) were from 1 of 4 SNFs not accepting Medicaid. Patients from SNFs accepting Medicaid were younger (79 versus 87, P < .001) and less frequently white (62% versus 97%, P < .001). The mean number of 9 possible information items available was lower for patients from SNFs that accept Medicaid (7.13 versus 8.15, P < .001). Emergency providers also reported lower satisfaction regarding access to information for residents from SNFs that accept Medicaid (P < .05). The association between residence in an SNF that accepts Medicaid and lower ED information scores remained after linear regression with clustering by SNF controlling for age, gender, and race. The most common source of information for residents from both types of SNFs was transfer papers from the SNF.

CONCLUSION

Less information is available to ED providers for patients from SNFs that accept Medicaid than for residents from SNFs that do not accept Medicaid. Further study is needed to examine this information gap.

Emergency department use by older adults: a literature review on trends, appropriateness, and consequences of unmet health care needs

Older adults use emergency departments (EDs) more than any other age group and are more prone to subsequent adverse events. This article reviews the literature on ED use by older adults within the context of evaluating their need for emergency care and the extent to which access to primary and supportive care services affect use. While a substantial research literature describes general patterns of ED use, there is much less research on ED use as a function of other health service use. Gaps in the research literature result in a limited understanding of the full scope of the issue and opportunities for practice and policy intervention.

An internet-based communication network for information transfer during patient transitions from skilled nursing facility to the emergency department

OBJECTIVES

To determine whether the implementation of an Internet-based communication system improves the amount of essential information conveyed between a skilled nursing facility (SNF) and the emergency department (ED) during patient care transitions.

DESIGN

Interventional; before and after.

SETTING

ED of an urban teaching hospital with approximately 55,000 visits per year and a 55-bed subacute free-standing rehabilitation facility (the SNF).

PARTICIPANTS

All patients transferred from the SNF to the ED over 16 months.

INTERVENTION

An Internet-based communication network with SNF-ED transfer form for communication during patient care transitions.

MEASUREMENTS

Nine elements of patient information assessed before and after intervention through chart review.

SECONDARY OUTCOMES

changes in efficiency of information transfer and staff satisfaction.

RESULTS

Two hundred thirty-four of 237 preintervention and all 276 postintervention care transitions were reviewed. The Internet communication network was used in 78 (26%) of all care transitions, peaking at 40% by the end of the study. There was more critical patient information (1.85 vs 4.29 of 9 elements; P<.001) contained within fewer pages of transfer documents (24.47 vs 5.15; P<.001) after the intervention. Staff satisfaction with communication was higher among ED physicians after the intervention.

CONCLUSION

The use of an Internet-based system increased the amount of information communicated during SNF-ED care transitions and significantly reduced the number of pages in which this information was contained.

The interface between residential aged care and the emergency department: a systematic review

BACKGROUND

emergency care for older people living in residential aged care facilities (RACF) is a complex area of health policy. The epidemiology of patient transfer between RACF and hospital emergency departments (ED), clinical outcomes and costs associated with transfer and efficacy of programs aiming to reduce transfer are not well known.

DESIGN

systematic review based on a comprehensive literature search in three electronic databases and published article reference lists.

RESULTS

the incidence of transfer from RACF to ED is >30 transfers/100 RACF beds/year in most studies. The casemix from RACF is varied and reflects that of the broad elderly population, with some risk difference. At least 40% of transfers are not admitted to hospital. There is insufficient data to fully address our other questions; however, hospitalisations from RACF can be reduced through advanced care planning, use of management guidelines for acute illnesses and improved primary care.

CONCLUSIONS

residents of RACF have a high annual risk of transfer to ED. The clinical benefit and cost effectiveness of ED care, and alternate programs to reduce ED transfer, cannot be confidently compared from published work. Further research is required to accurately describe these and to determine their comparative worth.

The impact of inpatient boarding on ED efficiency: a discrete-event simulation study

In this study, a discrete-event simulation approach was used to model Emergency Department's (ED) patient flow to investigate the effect of inpatient boarding on the ED efficiency in terms of the National Emergency Department Crowding Scale (NEDOCS) score and the rate of patients who leave without being seen (LWBS). The decision variable in this model was the boarder-released-ratio defined as the ratio of admitted patients whose boarding time is zero to all admitted patients. Our analysis shows that the Overcrowded(+) (a NEDOCS score over 100) ratio decreased from 88.4% to 50.4%, and the rate of LWBS patients decreased from 10.8% to 8.4% when the boarder-released-ratio changed from 0% to 100%. These results show that inpatient boarding significantly impacts both the NEDOCS score and the rate of LWBS patient and this analysis provides a quantification of the impact of boarding on emergency department patient crowding.

Fall-related hospitalization and facility costs among residents of institutions providing long-term care

PURPOSE

The purpose of this study was to estimate hospital and long-term-care costs resulting from falls in long-term-care facilities (LTCFs).

DESIGN AND METHODS

The study used a retrospective, pre/post with comparison group design. We used matching, based on propensity scores, to control for baseline differences between fallers and non-fallers. We estimated residents' propensity to fall from demographics, comorbidities, and reimbursement in the pre-period. The matched sample included 1,130 fallers and 1,130 non-fallers who were residents of a large, multifacility long-term-care chain. Cost estimates were based on information in the Minimum Data Set and were defined as hospital and LTCF reimbursements. We estimated fall-related costs as the difference between changes in costs for fallers and non-fallers from the pre- to post-period.

RESULTS

Fallers were substantially more likely to suffer fractures and hospitalizations in the post-period than were non-fallers. Fall-related LTCF and hospital costs were $6,259 (95% confidence interval = $2,034-$10,484) per resident per year. About 60% of this amount was attributable to higher hospitalization costs. Fallers were more likely to be discharged to hospitals or to die.

IMPLICATIONS

Falls in LTCFs are associated with costs of about $6,200 per resident per year. These results provide baseline estimates that one may use to estimate the cost-effectiveness of interventions to reduce fall rates.

Use of Advance Directives for Nursing Home Residents in the Emergency Department

Documented requests can ensure that patients' end-of-life care preferences are implemented, particularly in emergent circumstances. This study a) compared information on advance directives found in different sources of documentation in the hospital record of nursing home patients admitted through the emergency department and b) assessed emergency department clinicians' perceptions of how end-of-life care requests are communicated to them. Seven potential sources of documentation were reviewed in the medical records of 40 patients, and semistructured interviews were conducted with 10 emergency department clinicians. We found little concordance among sources of advance directive documentation. Our results suggest variability in documentation for nursing home patients on transfer to the emergency department, and that emergency department clinicians experience substantial difficulty in reliably obtaining information about advance directives. As treatment may vary based solely on available documentation, such information gaps may decrease the likelihood of adherence in the emergency department to patients' previously expressed care preferences.

The elderly in the emergency department: a critical review of problems and solutions

The elderly are an ever increasing population in overcrowded emergency departments (EDs) in many countries. They have multiple health problems and consume more time and resources than younger patients. They are more frequently admitted and experience adverse outcomes after they are discharged from the ED. These frail patients could require specific skills, instruments and organisational models of emergency care in order to look after their complex needs. As such, several approaches have been tried and tested to improve emergency care for them. This article analyses the epidemiological load and problems faced when confronted with elder ED patients. We critically review organisational models, clinical approaches and methodologies in order to reduce ED physicians' difficulties and to improve quality of care and outcomes for elder patients. Triage, clinical assessment and discharge are identified as critical moments during an emergency care process, and interesting and useful instruments are proposed as possible solutions.

Nursing home residents in emergency departments: a Foucauldian analysis

AIM

This paper is a critical review of current knowledge about use of emergency departments by nursing home residents.

BACKGROUND

A great deal of literature focuses on the challenges presented by older adults in acute care environments. Nursing home residents who transfer to emergency departments have been identified as being particularly problematic because they use considerable resources and their needs are not always amenable to acute interventions.

METHOD

A literature search was conducted in May 2006 using the CINAHL, Medline and Cochrane databases and Google Scholar with the keywords 'nursing home resident', 'long-term care resident', 'hospital transfer', and 'acute illness and emergency room'. No date restrictions were imposed. Foucault's concept of subjectivity was used to demonstrate how power derived from medical knowledge is used by emergency department personnel to construct nursing home residents as problematic.

FINDINGS

Knowledge about the use of emergency departments by nursing home residents has been derived mainly from retrospective record reviews, while the events in nursing homes that lead to transfers have been virtually ignored. Moreover, the primary focus of these investigations has been the effect of residents on emergency departments, rather than how residents themselves were affected.

CONCLUSION

Current understanding of the care of nursing home residents in emergency departments is embedded in a complex web of social, historical and political factors. Research is needed that considers multiple perspectives, including those of both emergency department and nursing home staff, residents and ambulance personnel who act as mediators between the two settings.

The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia

STUDY OBJECTIVE

We seek to determine the impact of emergency department (ED) crowding on delays in antibiotic administration for patients with community-acquired pneumonia.

METHODS

We performed a retrospective cohort study of adult patients admitted with community-acquired pneumonia from January 1, 2003, to April 31, 2005, at a single, urban academic ED. The main outcome was a delay (>4 hours from arrival) or nonreceipt of antibiotics in the ED. Eight ED crowding measures were assigned at triage. Multivariable regression and bootstrapping were used to test the adjusted impact of ED crowding measures of delayed (or no) antibiotics. Predicted probabilities were then calculated to assess the magnitude of the impact of ED crowding on the probability of delayed (or no) antibiotics.

RESULTS

In 694 patients, 44% (95% confidence interval [CI] 40% to 48%) received antibiotics within 4 hours and 92% (95% CI 90% to 94%) received antibiotics in the ED. Increasing levels of ED crowding were associated with delayed (or no) antibiotics, including waiting room number (odds ratio [OR] 1.05 for each additional waiting room patient [95% CI 1.01 to 1.10]) and recent ED length of stay for admitted patients (OR 1.14 for each additional hour [95% CI 1.04 to 1.25]). When the waiting room and recent length of stay were both at the lowest quartiles (ie, not crowded), the predicted probability of delayed (or no) antibiotics within 4 hours was 31% (95% CI 21% to 42%); when both were at the highest quartiles, the predicted probability was 72% (95% CI 61% to 81%).

CONCLUSION

ED crowding is associated with delayed and nonreceipt of antibiotics in the ED for patients admitted with community-acquired pneumonia.

Decisions About Transfer From Nursing Home to Emergency Department

PURPOSE

To describe how decisions occurred to transfer nursing home (NH) residents to emergency departments (EDs).

DESIGN

Three nursing homes (NHs) in Virginia were selected based on geographic and ownership variability. The phenomenon of concern was the decision-making process culminating in the transfer of NH residents to EDs. Sixteen transfers met the inclusion criteria and were analyzed. A minimum of two informants per transfer were interviewed, with a range of 2 to 4 interviews per transfer. All 42 respondents were asked to describe how the transfer decision was reached, to identify who participated in making the decision, and to describe any particular positive or negative aspects of reaching the transfer decision.

METHOD

Data were analyzed with hermeneutic phenomenological methods. Journal writing, audit trails, informal and formal member checks, and expert consultation were used to control bias.

FINDINGS

The three main themes identified were Consensus, Conflict, and Cogency. Consensus, or agreement, occurred when all decision participants reported similar interpretations as to the severity and acuity of the presenting problem or had shared interpretations of the best interests of the elder. When decision participants held dissimilar interpretations, conflict occurred. Decision participants used cogency by persuading others, in order to reach consensus.

CONCLUSIONS

The findings cannot be generalized to long-term care facilities across the US or to other countries, but they enhance understanding about some of the ways transfer decisions occur and the role of nurses in those transfers, especially when conflict arises.

Bouncing back: patterns and predictors of complicated transitions 30 days after hospitalization for acute ischemic stroke

OBJECTIVES

To identify predictors of complicated transitions within 30 days after discharge from hospitalization for acute stroke.

DESIGN

Retrospective analysis of administrative data.

SETTING

Four hundred twenty-two hospitals in the southern and eastern United States.

PARTICIPANTS

Thirty-nine thousand three hundred eighty-four Medicare beneficiaries aged 65 and older discharged after acute ischemic stroke from 1998 to 2000.

MEASUREMENTS

Complicated transition, defined as movement from less- to more-intensive care setting after hospital discharge, with hospital being most intensive and home without home health care being least intensive.

RESULTS

Twenty percent of patients experienced at least one complicated transition; 16% of those experienced more than one complicated transition. After adjustment using logistic regression, factors predicting any complicated transition included older age, African-American race, Medicaid enrollment, prior hospitalization, gastrostomy tube, chronic disease, length of stay, and discharge site. Patients with multiple complicated transitions were more likely to be African American (odds ratio (OR)=1.38, 95% confidence interval (CI)=1.13-1.68), be male (OR=1.21, 95% CI=1.04-1.40), have a prior diagnosis of fluid and electrolyte disorder (e.g., dehydration) (OR=1.23, 95% CI=1.07-1.43), have a prior hospitalization (OR=1.18, 95% CI=1.01-1.36), and be initially discharged to a skilled-nursing facility or long-term care (OR=1.22, 95% CI=1.04-1.44) than patients with only one complicated transition. They were less likely to be initially discharged to a rehabilitation center (OR=0.71, 95% CI=0.57-0.89).

CONCLUSION

Significant numbers of stroke patients experience complicated transitions soon after hospital discharge. Sociodemographic factors and initial discharge site distinguish patients with multiple complicated transitions. These factors may enable prospective identification and targeting of stroke patients at risk for "bouncing back."

Interface between residential aged care facilities and a teaching hospital emergency department in Western Australia

OBJECTIVE

To estimate the appropriateness of emergency department (ED) presentations by people aged>or=65 years living in residential care facilities.

DESIGN, SETTING AND PARTICIPANTS

Retrospective cohort study of older residents of residential care facilities who presented to the ED of the Royal Perth Hospital, Western Australia, between January and June 2002. Data were reviewed by an expert clinical panel.

MAIN OUTCOME MEASURES

Appropriateness of ED presentation, presenting complaint, involvement of a general practitioner/locum doctor prior to transfer, proportion of patients admitted to hospital from the ED, survival to discharge.

RESULTS

541 residents aged>or=65 years were transferred by ambulance to the ED, comprising 8.3% of all ED presentations of people in this age group. The mean age of the study cohort was 83.7 years (SD, 7.0 years), of which 68% were women. Of the 541 presentations, 326 (60%) resulted in hospital admission, and of these, 276 (85%) survived to hospital discharge. Musculoskeletal disorders accounted for 25% of all presentations, and 22% were falls-related; pneumonia (11% of presentations) was the single largest presenting complaint. ED attendance was deemed "inappropriate" for 71/541 cases (13.1%; 95% CI, 10.5%-16.2%); in only 25% of ED presentations was a GP/locum doctor involved prior to transfer.

CONCLUSIONS

The majority of ED presentations by aged care residents were considered to be appropriate, but there was scope for improvement in coordinating care between the hospital ED and residential care institutions.

A Pilot Study of Usefulness of Clinician–Patient Videoconferencing for Making Routine Medical Decisions in the Nursing Home

OBJECTIVES

To pilot and assess the role of videoconferencing in clinicians' medical decision-making and their interactions with nursing home residents (NHRs).

DESIGN

Paired virtual and bedside examinations. Face-to-face (FTF) examination of NHRs by off-site clinicians immediately followed videoconferencing between the same clinician-NHR pair.

SETTING

A 240-bed, county-managed, urban nursing home.

PARTICIPANTS

NHRs (n=35) and clinicians (n=3) receiving or providing routine care between 2002 and 2003.

MEASUREMENTS

Orders generated by clinicians, clinicians' ratings of videoconferencing, and coded review of video encounters. After both examinations, clinicians rated the encounters and generated orders necessary for NHRs. Orders were categorized and counted according to timing (before or after the FTF visit). Clinician-NHR interactions were assessed using coding videos with a 31-item instrument.

RESULTS

For 71% of the encounters, clinicians stated that videoconferencing facilitated their assessment. Difficulties included sound quality (19%) and participants' familiarity with videoconferencing (7%). Although NHRs were alert in 50% of encounters, 62% of alert NHRs did not indicate understanding of the recommended treatment.

CONCLUSION

FTF examination was superior for most assessments, but videoconferencing was judged to be valuable, especially for wound care. Even when NHRs were alert, informed medical decision-making by NHRs with their clinicians was limited. Enhancing videoconferencing quality and providing more training about informed decision-making using videoconferencing might improve the effectiveness of the technology.