Nursing home residents attending the emergency department: clinical characteristics and outcomes

End-of-Life Care during the COVID-19 Pandemic: Decreased Hospitalization of Nursing Home Residents at the End of Life

(1) Background: Nursing homes (NHs) face unique challenges in end-of-life care for their residents. High rates of hospitalization at the end of life are frequent, often for preventable conditions. The increased clinical uncertainty during the pandemic, the high symptom burden of the COVID-19 disease, and the challenges in communication with families and between care teams might impact the option to hospitalize NH residents at the end of life. (2) Materials and methods: The study covered a 3-year period and compared the hospitalization rates of the NH residents of a sample of Portuguese NH during the last year of life before and during the pandemic. A total of 387 deceased residents were included in the study. (3) Results: There were fewer hospitalizations in the last year of life during the pandemic period, although the proportion of deaths at hospitals was the same. Hospitalizations occurred closer to death, and with more serious clinical states. The lower rate of hospitalization was due to lower hospitalization due to infection; (4) Conclusions: The data suggest an improvement in end-of-life care practices during the pandemic period, with the decrease in hospitalizations being due to potentially burdensome hospitalizations. The importance of the role of physicians, nurses, and caregivers in this setting may be relatively independent of each other, and each may be targeted in end-of-life care training. Further study is recommended to clarify the implications of the results and if the changes can be sustained in the long term.

The development and validation of a conceptual definition of avoidable transitions from long-term care to the emergency department: A mixed methods study

Background/Objectives

Transitions to and from Emergency Departments (EDs) can be detrimental to long-term care (LTC) residents and burden the healthcare system. While reducing avoidable transfers is imperative, various terms are used interchangeably including inappropriate, preventable, or unnecessary transitions. Our study objectives were to develop a conceptual definition of avoidable LTC-ED transitions and to verify the level of stakeholder agreement with this definition.

Methods

The EXamining Aged Care Transitions study adopted an exploratory sequential mixed-method design. The study was conducted in 2015-2016 in 16 LTC facilities, 1 ED, and 1 Emergency Medical Service (EMS) in a major urban center in western Canada. Phase 1 included 80 participants, (healthcare aides, licensed practical nurses, registered nurses, LTC managers, family members of residents, and EMS staff). We conducted semistructured interviews (n = 25) and focus groups (n = 19). In Phase 2, 327 ED staff, EMS staff, LTC staff, and medical directors responded to a survey based on the qualitative findings.

Results

Avoidable transitions were attributed to limited resources in LTC, insufficient preventive care, and resident or family wishes. The definition generated was: A transition of an LTC resident to the ED is considered avoidable if: (a) Diagnostic testing, medical assessment, and treatment can be accessed in a timely manner by other means; (b) the reasons for a transfer are unclear and the transition would increase the disorientation, pain, or discomfort of a resident, outweighing a clear benefit of a transfer; and (c) the transition is against the wishes expressed by the resident over time, including through informal and undocumented conversations. There was a high level of agreement with the definition across the four participant groups.

Conclusions and Implications

To effectively reduce LTC resident avoidable transitions, stakeholders must share a common definition. Our conceptual definition may significantly contribute to improved care for LTC residents.

Emergency physicians' and nurses' perception on the adequacy of emergency calls for nursing home residents: a non-interventional prospective study

Introduction

A considerable percentage of daily emergency calls are for nursing home residents. With the ageing of the overall European population, an increase in emergency calls and interventions in nursing homes (NH) is to be expected. A proportion of these interventions and hospital transfers may be preventable and could be considered as inappropriate by prehospital emergency medical personnel. The study aimed to understand Belgian emergency physicians' and emergency nurses' perspectives on emergency calls and interventions in NHs and investigate factors contributing to their perception of inappropriateness.

Methods

An exploratory non-interventional prospective study was conducted in Belgium among emergency physicians and emergency nurses, currently working in prehospital emergency medicine. Electronic questionnaires were sent out in September, October and November 2023. Descriptive statistics were used to analyze the overall results, as well as to compare the answers between emergency physicians and emergency nurses about certain topics.

Results

A total of 114 emergency physicians and 78 nurses responded to the survey. The mean age was 38 years with a mean working experience of 10 years in prehospital healthcare. Nursing home staff were perceived as understaffed and lacking in competence, with an impact on patient care especially during nights and weekends. General practitioners were perceived as insufficiently involved in the patient's care, as well as often unavailable in times of need, leading to activation of Emergency Medical Services (EMS) and transfers of nursing home residents to the Emergency Department (ED). Advance directives were almost never available at EMS interventions and transfers were often not in accordance with the patient's wishes. Palliative care and pain treatment were perceived as insufficient. Emergency physicians and nurses felt mostly disappointed and frustrated. Additionally, differences in perception were noted between emergency physicians and nurses regarding certain topics. Emergency nurses were more convinced that the nursing home physician should be available 24/7 and that transfers could be avoided if nursing home staff had more authority regarding medical interventions. Emergency nurses were also more under the impression that pain management was inadequate, and emergency physicians were more afraid of the medical implications of doing too little during interventions than emergency nurses. Suggestions to reduce the number of EMS interventions were more general practitioner involvement (82%), better nursing home staff education/competences (77%), more nursing home staff (67%), mobile palliative care support teams (65%) and mobile geriatric nursing intervention teams (52%).

Discussion and conclusion

EMS interventions in nursing homes were almost never seen as necessary or indicated by emergency physicians and nurses, with the appropriate EMS level almost never being activated. The following key issues were found: shortages in numbers and competence of nursing home staff, insufficient primary care due to the unavailability of the general practitioner as well as a lack of involvement in patient care, and an absence of readily available advance directives. General practitioners should be more involved in the decision to call the Emergency Medical Services (EMS) and to transfer nursing home residents to the Emergency Department. Healthcare workers should strive for vigilance regarding the patients' wishes. The emotional burden of deciding on an avoidable hospital admission of nursing home residents, perhaps out of fear for medico-legal consequences if doing too little, leaves the emergency physicians and nurses frustrated and disappointed. Improvements in nursing home staffing, more acute and chronic general practitioner consultations, and mobile geriatric and palliative care support teams are potential solutions. Further research should focus on the structural improvement of the above-mentioned shortcomings.

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 visits by nursing home residents. A retrospective Italian study of administrative databases from 2015 to 2019

BACKGROUND

Visits to Emergency Departments (ED) can be traumatic for Nursing Home (NH) residents. In Italy, the rate of ED visits by NH residents was recently calculated as 3.3%. The reduction of inappropriate ED visits represents a priority for National Healthcare Systems worldwide. Nevertheless, research on factors associated with ED visits is still under-studied in the Italian setting. This study has two main aims: (i) to describe the baseline characteristics of NH residents visiting ED at regional level; (ii) to assess the characteristics, trends, and factors associated with these visits.

METHODS

A retrospective study of administrative data for five years was performed in the Piedmont Region. Data from 24,208 NH residents were analysed. Data were obtained by merging two ministerial databases of residential care and ED use. Sociodemographic and clinical characteristics of the residents, trends, and rates of ED visits were collected. A Generalized Linear Model (GLM) regression was used to evaluate the factors associated with ED visits.

RESULTS

In 5 years, 12,672 residents made 24,609 ED visits. Aspecific symptoms (45%), dyspnea (17%) and trauma (16%) were the most frequent problems reported at ED. 51% of these visits were coded as non-critical, and 58% were discharged to the NH. The regression analysis showed an increased risk of ED visits for men (OR = 1.61, 95% CI 1.51-1.70) and for residents with a stay in NH longer than 400 days (OR = 2.19, 95% CI 2.08-2.31).

CONCLUSIONS

Our study indicates that more than half of NH residents' ED visits could potentially be prevented by treating residents in NH. Investments in the creation of a structured and effective network within primary care services, promoting the use of health technology and palliative care approaches, could reduce ED visits and help clinicians manage residents on-site and remotely.

Impact of family involvement and an advance directive to not hospitalize on hospital transfers of residents in long-term care facilities

OBJECTIVE

With the rapidly aging population, the number of residents transferred to hospitals from long-term care facilities (LTCFs) is increasing globally. The objective of this study was to investigate the association between family involvement and an advance directive (AD) for not hospitalizing and hospital transfers among LTCF residents with dementia.

METHOD

Using the InterRAI assessment database from September 2014 to June 2019, we included 874 residents from 16 LTCFs in Japan.

RESULTS

Of the 874 participants, 19.0% had an AD for not hospitalizing, and 20.5% were transferred to hospitals. An AD for not hospitalizing decreased the likelihood of hospital transfers (p = 0.005). Multilevel logistic regression analysis showed that family involvement was not associated with hospital transfers (odds ratio [OR]: 1.18; 95% confidence interval [CI]: 0.77-1.80), while an AD for not hospitalizing was significantly associated with decreased hospital transfers (OR: 0.50; 95% CI: 0.28-0.89) among the LTCF residents.

CONCLUSIONS

Although ADs are not legally defined in Japan, we found that an AD for not hospitalizing decreased hospital transfers. Given that many older people tend to hesitate to express their wishes in clinical decision-making situations in Japan, regular discussions are necessary to help them express their care preferences while also documenting the discussions to ensure the residents receive high-quality care.

Unplanned Hospital Visits and Poor Oral Health With Undernutrition in Nursing Home Residents

OBJECTIVES

In 2021, the Japanese government began operating a long-term care (LTC) database called the Long-Term Care Information System for Evidence (LIFE). However, its utility has not been verified. Regarding unplanned hospital visits of nursing home residents, one of the challenges in LTC is that poor oral health with undernutrition could indicate high-risk residents. Therefore, this study examined the association between poor oral health with undernutrition assessed using the LIFE data and unplanned hospital visits of nursing home residents.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

The participants were 237 residents aged ≥65 years in 4 nursing homes in Japan. The analyses included 1041 LIFE data entries repeatedly measured for the participants every month and unplanned hospital visit data during the observation period.

METHODS

The participants' LIFE and unplanned hospital visit data were obtained from the nursing home providers. Poor oral health was defined using oral items included in the LIFE data and body mass index. Using the LIFE data, the association between poor oral health and unplanned hospital visits within 1 month after LIFE assessment entries was analyzed. The odds ratios (ORs) and 95% CIs were calculated using a generalized linear mixed model.

RESULTS

In total, 59 of 1041 LIFE data (5.7%) entries were unplanned hospital visits within 1 month after LIFE assessment. Among patient characteristics, significant differences were noted in dementia diagnosis [OR (95% CI): 2.66 (1.26-5.63)], although no significant differences were observed in other characteristics. Multivariate analysis using participant identification as a random effect confirmed that poor oral health was associated with unplanned hospital visits within 1 month [adjusted OR (95% CI): 2.63 (1.05-6.61)].

CONCLUSIONS AND IMPLICATIONS

Poor oral health assessed using the LIFE data could be used as an indicator to identify nursing home residents at high risk for unplanned hospital visits.

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.

Factors associated with avoidable hospital transfers among residents in Swiss nursing homes

Unplanned hospitalizations from nursing homes (NHs) may be considered potentially avoidable and can result in adverse resident outcomes. There is little information about the relationship between a clinical assessment conducted by a physician or geriatric nurse expert before hospitalization and an ensuing rating of avoidability. This study aimed to describe characteristics of unplanned hospitalizations (admitted residents with at least one night stay, emergency department visits were excluded) and to examine this relationship. We conducted a cohort study in 11 Swiss NHs and retrospectively evaluated data from the root cause analysis of 230 unplanned hospitalizations. A telephone assessment by a physician (p=.043) and the need for further medical clarification and treatment (p=<0.001) were the principal factors related to ratings of avoidability. Geriatric nurse experts can support NH teams in acute situations and assess residents while adjudicating unplanned hospitalizations. Constant support for nurses expanding their clinical role is still warranted.

Mobile X-ray services in nursing homes as an enabler to healthcare-in-place for residents: informal carers' views

BACKGROUND

Informal carers (ICs) of residents living in nursing homes (NH) have a key role in the care of residents, including making decisions about and providing care. As radiology has a role in decision making about care, it is important to understand IC's perspectives about resident's use of mobile X-ray services (MXS). The aim was to explore the perspectives of ICs of residents living in nursing homes about the use of MXS.

METHODS

From November 2020 to February 2021, twenty ICs of residents living in four nursing homes in different areas of one Australian city participated. Their perspectives of MXS, including benefits and barriers, were explored in semi-structured interviews. Data were analysed using thematic analysis.

RESULTS

ICs were resident's children (80%) and spouses (20%). One resident had received a MXS. Four themes were developed: (1) a priority for resident well-being, where ICs were positive about using MXS, because residents could receive healthcare without transfer; (2) MXS could reduce carer burden; (3) economic considerations, where MXS could reduce health system burden but the MXS call-out fee could result in health inequities; and (4) pathways to translation, including the need to improve consumer awareness of MXS, ensure effective processes to using MXS,, consider nursing home staff levels to manage MXS and ICs expectations about quality and availability of MXS.

CONCLUSIONS

ICs consider MXS can benefit resident well-being by potentially reducing transfers to hospital or radiology facilities and advocated equitable access. ICs cautioned that the quality and safety of healthcare delivered in nursing homes should equal what they would receive in hospitals.

Evaluation of the appropriateness of nursing home residents' transfer to emergency departments

INTRODUCTION

France is experiencing a steady increase in the number of residents living in nursing homes (NHs). Each year, 25% of these residents are hospitalized, half of them through emergency departments (EDs). A part of these transfers to EDs are unjustified and not without consequences. The first aim of our study is to evaluate the proportion of avoidable NHs resident transfer to EDs.

METHODS

An observational, prospective and multicentric study was conducted between January and August 2019 in the 6 EDs of a French county during 3 inclusion periods. A multidisciplinary expert panel determined the appropriateness of each ED transfer. The results were expressed in gross values and %. Expert agreement was assessed by Fleiss' kappa statistical measure.

RESULTS

Transfers were deemed avoidable in 12 to 35% of cases and appropriate in 53 to 81% of cases according to the experts. Fleiss' Kappa score on the concordance of the different experts' answers concerning the relevance of transfers was slight with k = 0.28 with a significant p-value (p < 0.0001). Infection could benefit of direct hospitalization whereas trauma/wound and acute heart/pulmonary failure are the most relevant reasons of presentation to the ED.

CONCLUSIONS

Too many ED transfers of NH residents remain avoidable. There is a disparity of results among the experts reflecting a limitation of this study related to the subjective nature of relevance. In a society where demographic projections predict a continuing aging population anywhere EDs are regularly crowded, it would be interesting to identify and prevent factors predisposing to ED transfer and consider alternative managements with a better geriatric and emergency physicians collaboration for this specific population.

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.

Trends and Characteristics of Potentially Preventable Emergency Department Visits Among Patients With Cancer in the US

IMPORTANCE

An initial step to reducing emergency department (ED) visits among patients with cancer is to identify the characteristics of patients visiting the ED and examine which of those visits could be prevented.

OBJECTIVE

To explore nationwide trends and characteristics of ED visits and examine factors associated with potentially preventable ED visits and unplanned hospitalizations among patients with cancer in the US.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data on ED visits from the National Hospital Ambulatory Medical Care Survey from January 1, 2012, to December 31, 2019; US Cancer Statistics reports were used to estimate new cancer cases each year. Frequencies and trends among 35 510 014 ED visits by adult patients (aged ≥18 years) with cancer were calculated.

MAIN OUTCOMES AND MEASURES

The primary outcome was potentially preventable ED visits, and secondary outcomes were unplanned hospitalizations and the immediacy of the ED visits. Potentially preventable ED visits were identified using the Centers for Medicare & Medicaid Services definition. The Emergency Severity Index, a triage algorithm that ranks patients based on the urgency of their health care condition, was used to measure the immediacy of ED visits (immediate [most urgent], emergent, urgent, less urgent, and nonurgent), with the categories of immediate and emergent classified as high acuity. The Wilcoxon rank sum test was used to calculate trends in ED visits among patients with cancer over time. Multivariable logistic regression analyses were performed to examine the associations of patient, hospital, and temporal factors with potentially preventable ED use and ED use resulting in hospitalization.

RESULTS

Among 854 911 106 ED visits, 35 510 014 (4.2%) were made by patients with cancer (mean [SD] age, 66.2 [16.2] years); of those, 55.2% of visits were among women, 73.2% were among non-Hispanic White individuals, 89.8% were among patients living in a private residence, and 54.3% were among Medicare enrollees. A total of 18 316 373 ED visits (51.6%) were identified as potentially preventable, and 5 770 571 visits (21.3%) were classified as high acuity. From 2012 to 2019, potentially preventable ED visits increased from 1 851 692 to 3 214 276. Pain (36.9%) was the most common reason for potentially preventable ED visits. The number of patients who visited an ED because of pain increased from 1 192 197 in 2012 to 2 405 849 in 2019 (a 101.8% increase). Overall, 28.9% of ED visits resulted in unplanned hospitalizations, which did not change significantly over time (from 32.2% in 2012 to 26.6% in 2019; P = .78 for trend). Factors such as residence in a nursing home (odds ratio, 1.73; 95% CI, 1.25-2.41) were positively associated with having a potentially preventable ED visit, and factors such as the presence of more than 1 comorbidity (odds ratio, 1.82; 95% CI, 1.43-2.32) were positively associated with having an unplanned hospitalization.

CONCLUSIONS AND RELEVANCE

In this study, 51.6% of ED visits among patients with cancer were identified as potentially preventable, and the absolute number of potentially preventable ED visits increased substantially between 2012 and 2019. These findings highlight the need for cancer care programs to implement evidence-based interventions to better manage cancer treatment complications, such as uncontrolled pain, in outpatient and ambulatory settings.

Managing the Impact of COVID-19 in Nursing Homes and Long-Term Care Facilities: An Update

Older adults in nursing homes are at greatest risk of morbidity and mortality from SARS-CoV-2 infection. Nursing home residents constituted one-third to more than half of all deaths during the early waves of the COVID-19 pandemic. Following this, widespread adaptation of infection prevention and control measures and the supply and use of personal protective equipment resulted in a significant decrease in nursing home infections and deaths. For nursing homes, the most important determinant of experiencing a SARS-CoV-2 outbreak in the first instance appears to be community-transmission levels (particularly with variants of concern), although nursing home size and quality, for-profit status, and sociodemographic characteristics are also important. Use of visitation bans, imposed to reduce the impact of COVID-19 on residents, must be delicately balanced against their impact on resident, friend or family, and staff well-being. The successful rollout of primary vaccination has resulted in a sharp decrease in morbidity and mortality from SARS-CoV-2 in nursing homes. However, emerging evidence suggests that vaccine efficacy may wane over time, and the use of a third or additional vaccine "booster" doses in nursing home residents restores protection afforded by primary vaccination. Ongoing monitoring of vaccine efficacy in terms of infection, morbidity, and mortality is crucial in this vulnerable group in informing ongoing SARS-CoV-2 vaccine boosting strategies. Here, we detail the impact of SARS-CoV-2 on nursing home residents and discuss important considerations in the management of nursing home SARS-CoV-2 outbreaks. We additionally examine the use of testing strategies, nonpharmacologic outbreak control measures and vaccination strategies in this cohort. Finally, the impact of SARS-CoV-2 on the sector is reflected on as we emphasize the need for adoption of universal standards of medical care and integration with wider public health infrastructure in nursing homes in order to provide a safe and effective long-term care sector.

Inappropriate and potentially avoidable emergency department visits of Swiss nursing home residents and their resource use: a retrospective chart-review

Background

Emergency department (ED) visits for nursing home residents lead to higher morbidity and mortality. Therefore, inappropriate visits (for conditions treatable elsewhere) or potentially avoidable visits (those avoidable through adequate chronic care management) must be minimized. This study aimed to investigate factors and resource consumption patterns associated with inappropriate and potentially avoidable visits in a Swiss tertiary hospital.

Methods

This is a single-center retrospective chart review in an urban Swiss university hospital ED. A consecutive sample of 1276 visits by nursing home residents (≥ 65 years old), recorded between January 1, 2015 and December 31, 2017 (three calendar years) were included. Case characteristics were extracted from ED electronic documentation. Appropriateness was assessed via a structured Appropriateness Evaluation Protocol; potentially avoidable visits—measured as ambulatory-care sensitive conditions (ACSCs)—were analyzed separately. Inter-group differences concerning ED resource use were tested respectively with chi-square or Wilcoxon rank sum tests. To identify predictors of inappropriate or potentially-avoidable visits, we used multivariable logistic regression analysis.

Results

Six percent of visits were rated as inappropriate: they had lower triage levels (OR 0.55 [95%-CI 0.33-0.92], p=0.024) and, compared to ambulance calls, they had higher odds of initiation via either patient-initiated walk-in (OR 3.42 [95%-CI 1.79-6.55], p≤0.001) or GP referrals (OR 2.13 [95%-CI 1.16-3.90], p=0.015). For inappropriate visits, overall ED resource use was significantly lower (median 568 vs. 1403 tax points, p≤0.001). Of all visits included, 29% were due to (often potentially-avoidable) ACSCs. In those cases, compared to ambulance initiation, odds of being potentially-avoidable were considerably lower for walk-in patients (OR 0.46 [95%-CI 0.27-0.77], p=0.004) but higher for GP referrals (OR 1.40 [95%-CI 1.00-1.94], p=0.048). Nurse work (93 tax points vs. 64, p≤0.001) and laboratory resource use (334 tax points vs. 214, p≤0.001) were higher for potentially-avoidable ED visits.

Conclusions

We revealed substantial differences between the investigated groups. While nearly one third of ED visits from nursing homes were potentially avoidable, inappropriate visits were lower in numbers and not resource-intensive. Further research is required to differentiate potentially avoidable visits from inappropriate ones and to determine these findings’ public health implications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03308-9.

Establishing the Geriatric Emergency Department Intervention in Queensland emergency departments: a qualitative implementation study using the i-PARIHS model

BACKGROUND

Frail older adults require specific, targeted care and expedited shared decision making in the emergency department (ED) to prevent poor outcomes and minimise time spent in this chaotic environment. The Geriatric Emergency Department Intervention (GEDI) model was developed to help limit these undesirable consequences. This qualitative study aimed to explore the ways in which two hospital implementation sites implemented the structures and processes of the GEDI model and to examine the ways in which the i-PARIHS (innovation-Promoting Action on Research Implementation in Health Services) framework influenced the implementation.

METHODS

Using the i-PARIHS approach to implementation, the GEDI model was disseminated into two hospitals using a detailed implementation toolkit, external and internal facilitators and a structured program of support. Following implementation, interviews were conducted with a range of staff involved in the implementation at both sites to explore the implementation process used. Transcribed interviews were analysed for themes and sub-themes.

RESULTS

There were 31 interviews with clinicians involved in the implementation, conducted across two hospitals, including interviews with the two external facilitators. Major themes identified included: (i) elements of the GEDI model adopted or (ii) adapted by implementation sites and (iii) factors that affected the implementation of the GEDI model. Both sites adopted the model of care and there was general support for the GEDI approach to the management of frail older people in the ED. Both sites adapted the structure of the GEDI team and the expertise of the team members to suit their needs and resources. Elements such as service focus, funding, staff development and service evaluation were initially adopted but adaptation occurred over time. Resourcing and cost shifting issues at the implementation sites and at the site providing the external facilitators negatively impacted the facilitation process.

CONCLUSIONS

The i-PARIHS framework provided a pragmatic approach to the implementation of the evidenced-based GEDI model. Passionate, driven clinicians ensured that successful implementation occurred despite unanticipated changes in context at both the implementation and host facilitator sites as well as the absence of sustained facilitation support.

Previous SARS-CoV-2 Infection, Age, and Frailty Are Associated With 6-Month Vaccine-Induced Anti-Spike Antibody Titer in Nursing Home Residents

OBJECTIVES

Older nursing home residents make up the population at greatest risk of morbidity and mortality from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. No studies have examined the determinants of long-term antibody responses post vaccination in this group.

DESIGN

Longitudinal cohort study.

SETTING AND PARTICIPANTS

Residents from 5 nursing homes assessed before vaccination, and 5 weeks and 6 months post vaccination, with the BNT162b2 messenger RNA SARS-CoV-2 vaccine.

METHODS

Comprehensive clinical assessment was performed, including assessment for comorbidity, frailty, and SARS-CoV-2 infection history. Serum nucleocapsid and anti-spike receptor binding domain (RBD) antibodies were analyzed at all timepoints. An in vitro angiotensin-converting enzyme (ACE2) receptor-spike RBD neutralization assay assessed serum neutralization capacity.

RESULTS

Of 86 participants (81.1 ± 10.8 years; 65% female), just under half (45.4%; 39 of 86) had evidence of previous SARS-CoV-2 infection. All participants demonstrated a significant antibody response to vaccination at 5 weeks and a significant decline in this response by 6 months. SARS-CoV-2 infection history was the strongest predictor of antibody titer (log-transformed) at both 5 weeks [β: 3.00; 95% confidence interval (CI): 2.32-3.70; P < .001] and 6 months (β: 3.59; 95% CI: 2.89-4.28; P < .001). Independent of SARS-CoV-2 infection history, both age in years (β: -0.05; 95% CI: -0.08 to -0.02; P < .001) and frailty (β: -0.22; 95% CI: -0.33 to -0.11; P < .001) were associated with a significantly lower antibody titer at 6 months. Anti-spike antibody titers at both 5 weeks and 6 months significantly correlated with in vitro neutralization capacity.

CONCLUSIONS AND IMPLICATIONS

In older nursing home residents, SARS-CoV-2 infection history was the strongest predictor of anti-spike antibody titers at 6 months, whereas age and frailty were independently associated with lower titers at 6 months. Antibody titers significantly correlated with in vitro neutralization capacity. Although older SARS-CoV-2 naïve nursing home residents may be particularly vulnerable to breakthrough SARS-CoV-2 infection, the relationship between antibody titers, SARS-CoV-2 infection, and clinical outcomes remains to be fully elucidated in this vulnerable population.

Approaches to multidrug-resistant organism prevention and control in long-term care facilities for older people: a systematic review and meta-analysis

BACKGROUND

Despite clear evidence of benefits in acute-care hospitals, controversy over the effectiveness of IPC measures for MDROs is perceptible and evidence-based practice has not been established.

OBJECTIVE

To investigate the effects of IPC interventions on MDRO colonization and infections in LTCFs.

DATA SOURCES

Ovid MEDLINE, EMBASE, and CINAHL from inception to September 2020.

ELIGIBILITY CRITERIA

Original and peer-reviewed articles examining the post-intervention effects on MDRO colonization and infections in LTCFs.

INTERVENTIONS

(i) Horizontal interventions: administrative engagement, barrier precautions, education, environmental cleaning, hand hygiene, performance improvement, and source control; and (ii) vertical intervention: active surveillance plus decolonization.

STUDY APPRAISAL AND SYNTHESIS

We employed a random-effects meta-analysis to estimate the pooled risk ratios (pRRs) for methicillin-resistant Staphylococcus aureus (MRSA) colonization by intervention duration; and conducted subgroup analyses on different intervention components. Study quality was assessed using Cochrane risk of bias tools.

RESULTS

Of 3877 studies identified, 19 were eligible for inclusion (eight randomized controlled trials (RCTs)). Studies reported outcomes associated with MRSA (15 studies), vancomycin-resistant Enterococci (VRE) (four studies), Clostridium difficile (two studies), and Gram-negative bacteria (GNB) (two studies). Eleven studies were included in the meta-analysis. The pRRs were close to unity regardless of intervention duration (long: RR 0.81 [95% CI 0.60-1.10]; medium: RR 0.81 [95% CI 0.25-2.68]; short: RR 0.95 [95% CI 0.53-1.69]). Vertical interventions in studies with a small sample size showed significant reductions in MRSA colonization while horizontal interventions did not. All studies involving active administrative engagement reported reductions. The risk of bias was high in all but two studies.

CONCLUSIONS

Our meta-analysis did not show any beneficial effects from IPC interventions on MRSA reductions in LTCFs. Our findings highlight that the effectiveness of interventions in these facilities is likely conditional on resource availability-particularly decolonization and barrier precautions, due to their potential adverse events and uncertain effectiveness. Hence, administrative engagement is crucial for all effective IPC programmes. LTCFs should consider a pragmatic approach to reinforce standard precautions as routine practice and implement barrier precautions and decolonization to outbreak responses only.

Characteristics of outpatient emergency department visits of nursing home residents: an analysis of discharge letters

BACKGROUND

Unplanned emergency department (ED) visits of nursing home residents (NHR) are common, with many transfers not leading to hospitalization. However, there is little research on what diagnostic and therapeutic measures are performed during visits.

AIMS

We analyzed underlying diagnoses, characteristics and performed medical procedures of unplanned outpatient ED visits by NHR.

METHODS

We conducted a multi-center study of 14 nursing homes (NHs) in northwestern Germany in 03/2018-07/2019. Hospital transfers were documented by nursing staff using a standardized questionnaire for 12 months. In addition, discharge letters were used to collect information about the respective transfer, its reasons and the extend of the medical services performed in the ED.

RESULTS

A total of 161 unplanned ED visits were included (mean age: 84.2 years; 68.3% females). The main transfer reasons were trauma (59.0%), urinary catheter and nutritional probe problems (overall 10.6%; male NHR 25.5%) and altered mental state (9.9%). 32.9% where discharged without imaging or blood test prior. 67.4% of injured NHR (n = 95) required no or only basic wound care. Catheter-related problems (n = 17) were mainly treated by changing an existing suprapubic catheter (35.3%) and by flushing the pre-existing catheter (29.4%).

DISCUSSION

Our data suggest that the diagnostic and therapeutic interventions performed in ED, often do not exceed general practitioner (GP) care and many ED visits seem to be unnecessary.

CONCLUSION

Better coordination and consultation with GPs as well as better training of nursing staff in handling catheter problems could help to reduce the number of ED visits.

Perceptions and experiences of residents and relatives of emergencies in care homes: a systematic review and metasynthesis of qualitative research

Background

the perceptions and experiences of care home residents and their families are important for understanding and improving the quality of emergency care.

Methods

we conducted a systematic review and metasynthesis to understand the perceptions and experiences of care home residents and their family members who experienced medical emergencies in a care home setting. The review protocol was registered in PROSPERO (CRD42020167018). We searched five electronic databases, MEDLINE, CINAHL, PubMed, Cochrane Library and PsycINFO, supplemented with internet searches and forward and backward citation tracking from included studies and review articles. Data were synthesised thematically following the Thomas and Harden approach. The Critical Appraisal Skills Programme qualitative checklist was used to assess the quality of studies included in this review.

Results

of the 6,140 references retrieved, 10 studies from four countries (Australia, Canada, UK and USA) were included in the review and metasynthesis. All the included studies were assessed as being of good quality. Through an iterative approach, we developed six analytical themes: (i) infrastructure and process requirements in care homes to prevent and address emergencies; (ii) the decision to transfer to hospital; (iii) experiences of transfer and hospitalisation for older patients; (iv) good communication is vital for desirable outcomes; (v) legal, regulatory and ethical concerns and (vi) trusting relationships enabled residents to feel safe.

Conclusions

the emergency care experience for care home residents can be enhanced by ensuring resources, staff capacity and processes for high quality care and trusting relationships between staff, patients and relatives, underpinned by good communication and attention to ethical practice.

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.

Where Skilled Nursing Facility Residents Get Acute Care: Is the Emergency Department the Medical Home?

OBJECTIVES

This study aimed to characterize the distribution of acute care visits among Medicare beneficiaries receiving skilled nursing facility (SNF) services.

METHODS

We conducted a cross-sectional analysis of a 20% sample of continuously enrolled Medicare beneficiaries in the 2012 Chronic Condition Warehouse data set. Beneficiaries were grouped by the number of days of SNF services, and acute care visits were categorized as "before SNF," "during SNF," or "after SNF."

RESULTS

Among the 10,717,786 Medicare beneficiaries analyzed, 384,312 (3.6%) had at least one SNF stay.

DISCUSSION

Beneficiaries who received SNF services had a higher proportion of acute care visits made to emergency departments (EDs) than beneficiaries who did not receive SNF services. Also, a higher proportion of acute care visits were made to EDs by beneficiaries after a SNF stay in comparison to residents actively residing in a SNF. The acute care capabilities of SNFs and post-SNF transitions of care to the community setting are discussed.

Unplanned hospital transfers from nursing homes: who is involved in the transfer decision? Results from the HOMERN study

Background

Emergency department visits and hospital admissions are common among nursing home residents (NHRs) and seem to be higher in Germany than in other countries. Yet, research on characteristics of transfers and involved persons in the transfer decision is scarce.

Aims

The aim of this study was to analyze the characteristics of hospital transfers from nursing homes (NHs) focused on contacts to physicians, family members and legal guardians prior to a transfer.

Methods

We conducted a multi-center study in 14 NHs in the regions Bremen and Lower Saxony (Northwestern Germany) between March 2018 and July 2019. Hospital transfers were documented for 12 months by nursing staff using a standardized questionnaire. Data were derived from care records and perspectives of nursing staff and were analyzed descriptively.

Results

Among 802 included NHRs, n = 535 unplanned hospital transfers occurred of which 63.1% resulted in an admission. Main reasons were deterioration of health status (e.g. fever, infections, dyspnea and exsiccosis) (35.1%) and falls/accidents/injuries (33.5%). Within 48 h prior to transfer, contact to at least one general practitioner (GP)/specialist/out-of-hour-care physician was 46.2% and varied between the NHs (range: 32.3–83.3%). GPs were involved in only 34.8% of transfer decisions. Relatives and legal guardians were more often informed about transfer (62.3% and 66.8%) than involved in the decision (21.8% and 15.1%).

Discussion

Contacts to physicians and involvement of the GP were low prior to unplanned transfers. The ranges between the NHs may be explained by organizational differences.

Conclusion

Improvements in communication between nursing staff, physicians and others are required to reduce potentially avoidable transfers.

Electronic supplementary material

The online version of this article (10.1007/s40520-020-01751-5) contains supplementary material, which is available to authorized users.

Home FIRsT: interdisciplinary geriatric assessment and disposition outcomes in the Emergency Department

BACKGROUND

Older people in the Emergency Department (ED) are clinically heterogenous and some presentations may be better suited to alternative out-of-hospital pathways. A new interdisciplinary comprehensive geriatric assessment (CGA) team (Home FIRsT) was embedded in our acute hospital's ED in 2017.

AIM

To evaluate if routinely collected CGA metrics were associated with ED disposition outcomes.

DESIGN

Retrospective observational study.

METHODS

We included all first patients seen by Home FIRsT between 7^th May and 19^th October 2018. Collected measures were sociodemographic, baseline frailty (Clinical Frailty Scale), major diagnostic categories, illness acuity (Manchester Triage Score) and cognitive impairment/delirium (4AT). Multivariate binary logistic regression models were computed to predict ED disposition outcomes: hospital admission; discharge to GP and/or community services; discharge to specialist geriatric outpatients; discharge to the Geriatric Day Hospital.

RESULTS

In the study period, there were 1,045 Home FIRsT assessments (mean age 80.1 years). For hospital admission, strong independent predictors were acute illness severity (OR 2.01, 95% CI 1.50-2.70, P<0.001) and 4AT (OR 1.26, 95% CI 1.13 - 1.42, P<0.001). Discharge to specialist outpatients (e.g. falls/bone health) was predicted by musculoskeletal/injuries/trauma presentations (OR 6.45, 95% CI 1.52 - 27.32, P=0.011). Discharge to the Geriatric Day Hospital was only predicted by frailty (OR 1.52, 95% CI 1.17 - 1.97, P=0.002). Age and sex were not predictive in any of the models.

CONCLUSIONS

Routinely collected CGA metrics are useful to predict ED disposition. The ability of baseline frailty to predict ED outcomes needs to be considered together with acute illness severity and delirium.

Machine Learning for Predictive Modelling of Ambulance Calls

A novel machine learning approach is presented in this paper, based on extracting latent information and using it to assist decision making on ambulance attendance and conveyance to a hospital. The approach includes two steps: in the first, a forward model analyzes the clinical and, possibly, non-clinical factors (explanatory variables), predicting whether positive decisions (response variables) should be given to the ambulance call, or not; in the second, a backward model analyzes the latent variables extracted from the forward model to infer the decision making procedure. The forward model is implemented through a machine, or deep learning technique, whilst the backward model is implemented through unsupervised learning. An experimental study is presented, which illustrates the obtained results, by investigating emergency ambulance calls to people in nursing and residential care homes, over a one-year period, using an anonymized data set provided by East Midlands Ambulance Service in United Kingdom.

Reshaping healthcare delivery for elderly patients: the role of community paramedicine; a systematic review

Background

Healthcare systems are overloaded and changing. In response to growing demands on the healthcare systems, new models of healthcare delivery are emerging. Community paramedicine is a novel approach in which paramedics use their knowledge and skills beyond emergency health response to contribute to preventative and rehabilitative health. In our systematic review, we aimed to identify evidence of the community paramedicine role in care delivery for elderly patients, with an additional focus on palliative care, and the possible impact of this role on the wider healthcare system.

Methods

A systematic review of peer-reviewed literature from MEDLINE, Embase, CINAHL, and Web of Sciences was undertaken to identify relevant full-text articles in English published until October 3, 2019. Additional inclusion criteria were studies focussing on extended care paramedics or community paramedics caring for elderly patients. Case studies were excluded. All papers were screened by at least two authors and underwent a quality assessment, using the Joanna Briggs Institute appraisal checklists for cross sectional, qualitative, cohort, and randomised controlled trial studies to assess the methodological quality of the articles. A process of narrative synthesis was used to summarise the data.

Results

Ten studies, across 13 articles, provided clear evidence that Community Paramedic programs had a positive impact on the health of patients and on the wider healthcare system. The role of a Community Paramedic was often a combination of four aspects: assessment, referral, education and communication. Limited evidence was available on the involvement of Community Paramedics in palliative and end-of-life care and in care delivery in residential aged care facilities. Observed challenges were a lack of additional training, and the need for proper integration and understanding of their role in the healthcare system.

Conclusions

The use of community paramedics in care delivery could be beneficial to both patients’ health and the wider healthcare system. They already play a promising role in improving the care of our elderly population. With consistent adherence to the training curriculum and effective integration within the wider healthcare system, community paramedics have the potential to take on specialised roles in residential aged care facilities and palliative and end-of-life care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-06037-0.

Geriatric assessment for older adults admitted to the emergency department: A systematic review and meta-analysis

BACKGROUND

Older adults are the most frequent users of emergency services. Comprehensive geriatric assessment (CGA) can help identify high-risk older adults at an early stage. We conducted a systematic review and meta-analysis to identify and evaluate CGA tools used in the emergency department (ED), analyze their predictive validity for adverse outcomes and recommend tools for this particular situation.

METHODS

We systematically searched Medline, Web of Science and CENTRAL for eligible articles published in peer-reviewed journals that observed patients ≥65 years admitted to the ED, used at least one assessment tool and reported adverse outcomes of interest. We performed a descriptive analysis and a bivariate meta-analysis of the diagnostic accuracy and predictive validity of the assessment tools for the chosen adverse outcomes.

RESULTS

28 eligible studies were included. The pooled sensitivity (95% CI) of the assessment tools for predicting mortality within short (28-90 days) and long (180-365 days) periods after the first ED visit was 0.77 (0.61-0.89) and 0.79 (0.46-0.96), respectively, with specificity (95% CI) values of 0.45 (0.32-0.59) and 0.37 (0.14-0.65). These findings indicate that the tools used in the included studies had modest predictive accuracy for mortality and were more appropriate for identifying individuals at high risk of readmission in the short term than in the long term.

CONCLUSIONS

Early use of assessment tools in the ED might improve clinical decision making and reduce negative outcomes for older adults.

Reducing Hospital Transfers from Aged Care Facilities: A Large-Scale Stepped Wedge Evaluation

BACKGROUND/OBJECTIVES

Older people living in residential aged care facilities (RACFs) experience acute deterioration requiring assessment and decision making. We evaluated the impact of a large-scale regional Aged Care Emergency (ACE) program in reducing hospital admissions and emergency department (ED) transfers.

DESIGN

A stepped wedge nonrandomized cluster trial with 11 steps, implemented from May 2013 to August 2016.

SETTING

A large regional and rural area of northern and western New South Wales, Australia.

PARTICIPANTS

Nine hospital EDs and 81 RACFs participated in the evaluation.

INTERVENTION

The ACE program is an integrated nurse-led intervention underpinned by a community of practice designed to improve the capability of RACFs managing acutely unwell residents. It includes telephone support, evidence-based algorithms, defining goals of care for ED transfer, case management in the ED, and an education program.

MEASUREMENTS

ED transfers and subsequent hospital admissions were collected from administrative data including 13 months baseline and 9 months follow-up.

RESULTS

A total of 18,837 eligible ED visits were analyzed. After accounting for clustering by RACFs and adjusting for time of the year as well as RACF characteristics, a statistically significant reduction in hospital admissions (adjusted incident rate ratio = .79; 95% confidence interval [CI] = .68-.92); P = .0025) was seen (i.e., residents were 21% less likely to be admitted to the hospital). This was also observed in ED visit rates (adjusted incidence rate ratio = .80; 95% CI = .69-.92; P = .0023) (i.e., residents were 20% less likely to be transferred to the ED). Seven-day ED re-presentation fell from 5.7% to 4.9%, and 30-day hospital readmissions fell from 12% to 10%.

CONCLUSION

The stepped wedge design allowed rigorous evaluation of a real-world large-scale intervention. These results confirm that the ACE program can be scaled up to a large geographic area and can reduce ED visits and hospitalization of older people with complex healthcare needs living in RACFs.

COVID-19 highlights the need for universal adoption of standards of medical care for physicians in nursing homes in Europe

The nursing home sector has seen a disproportionately high number of deaths as part of the COVID-19 pandemic. This reflects, in part, the frailty and vulnerability of older people living in care homes but has also, in part, been a consequence of the failure to include care homes in the systematic planning of a response to COVID, as well as a measure of neglect of standards and quality improvement in the sector. In response, the EUGMS published a set of medical standards of care developed in consultation with experts across its member national societies in 2015. The standards consisted of seven core principles of medical care for physicians working in nursing homes as a first step in developing a programme of clinical, academic and policy engagement in improving medical care for older people who are living and frequently also dying as residents in nursing homes. The gravity of the concerns arising for nursing home care from the COVID-19 pandemic, as well as emerging insights on care improvement in nursing homes indicate that an update of these medical standards is timely. This was performed by the writing group from the original 2015 guidelines and is intended as an interim measure pending a more formal review incorporating a systematic review of emerging literature and a Delphi process.

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.

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.

Care home residents who die in hospital: exploring factors, processes and experiences

BACKGROUND

Care home residents are increasingly frail with complex health and social care needs. Their transfer to hospital at the end-of-life can be associated with unwanted interventions and distress. However, hospitals do enable provision of care that some residents wish to receive. We aimed to explore the factors that influence hospital admission of care home residents who then died in hospital.

METHODS

This study combined in-depth case note review of care home residents dying in two Scottish teaching hospitals during a 6-month period and semi-structured interviews with a purposive sample of 26 care home staff and two relatives.

RESULTS

During the 6-month period, 109 care home residents died in hospital. Most admissions occurred out-of-hours (69%) and most were due to a sudden event or acute change in clinical condition (72%). Length of stay in hospital before death was short, with 42% of deaths occurring within 3 days. Anticipatory Care Planning (ACP) regarding hospital admission was documented in 44%.Care home staff wanted to care for residents who were dying; however, uncertain trajectories of decline, acute events, challenges of ACP, relationship with family and lack of external support impeded this.

CONCLUSIONS

Managing acute changes on the background of uncertain trajectories is challenging in care homes. Enhanced support is required to improve and embed ACP in care homes and to provide rapid, 24 hours-a-day support to manage difficult symptoms and acute changes.

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.

The emergency care model: A new paradigm for skilled nursing facilities

The population of individuals age 65 and older is increasing in the United States. One third of these individuals will utilize nursing home care before death. Nursing home residents ("NHR") average 1.8 emergency department visits annually. Improving the quality of nursing home care is of vital importance. This project describes a new paradigm for the management of acute emergent health issues affecting NHR. The model features a multidisciplinary team coordinated by emergency providers resulting in a 55% reduction in unplanned hospital admissions compared to skilled nursing facility regional data. Additionally, a reduction in ancillary lab costs was observed. Implementation of this paradigm on a national scale could result in a projected cost savings in excess of $10 billion per year for the Center for Medicare and Medicaid Services ("CMS").

Understanding which people with dementia are at risk of inappropriate care and avoidable transitions to hospital near the end-of-life: a retrospective cohort study

BACKGROUND

transitions between care settings near the end-of-life for people with dementia can be distressing, lead to physical and cognitive deterioration, and may be avoidable.

OBJECTIVE

to investigate determinants of end-of-life hospital transitions, and association with healthcare use, among people with dementia.

DESIGN

retrospective cohort study.

SETTING

electronic records from a mental health provider in London, linked to national mortality and hospital data.

SUBJECTS

people with dementia who died in 2007-2016.

METHODS

end-of-life hospital transitions were defined as: multiple admissions in the last 90 days (early), or any admission in the last three days of life (late). Determinants were assessed using logistic regression.

RESULTS

of 8,880 people, 1,421 (16.0%) had at least one end-of-life transition: 505 (5.7%) had early, 788 (8.9%) late, and 128 (1.5%) both types. Early transitions were associated with male gender (OR 1.33, 95% CI 1.11-1.59), age (>90 vs <75 years OR 0.69, 95% CI 0.49-0.97), physical illness (OR 1.52, 95% CI 1.20-1.94), depressed mood (OR 1.49, 95% CI 1.17-1.90), and deprivation (most vs least affluent quintile OR 0.58, 95% CI 0.37-0.90). Care home residence was associated with fewer early (OR 0.63, 95% CI 0.53 to 0.76) and late (OR 0.80, 95% CI 0.65 to 0.97) transitions. Early transitions were associated with more hospital admissions throughout the last year of life compared to those with late and no transitions (mean 4.56, 1.89, 1.60; P < 0.001).

CONCLUSIONS

in contrast to late transitions, early transitions are associated with higher healthcare use and characteristics that are predictable, indicating potential for prevention.

The scientific evidence for a potential link between confusion and urinary tract infection in the elderly is still confusing - a systematic literature review

Background

Non-specific symptoms, such as confusion, are often suspected to be caused by urinary tract infection (UTI) and continues to be the most common reason for suspecting a UTI despite many other potential causes. This leads to significant overdiagnosis of UTI, inappropriate antibiotic use and potential harmful outcomes. This problem is particularly prevalent in nursing home settings.

Methods

A systematic review of the literature was conducted assessing the association between confusion and UTI in the elderly. PubMed, Scopus and PsychInfo were searched with the following terms: confusion, delirium, altered mental status, acute confusional state, urinary tract infection, urine infection, urinary infection and bacteriuria. Inclusion criteria and methods were specified in advance and documented in the protocol, which was published with PROSPERO (registration ID: CRD42015025804). Quality assessment was conducted independently by two authors. Data were extracted using a standardised extraction tool and a qualitative synthesis of evidence was made.

Results

One thousand seven hunderd two original records were identified, of which 22 were included in the final analysis. The quality of these included studies varied, with frequent poor case definitions for UTI or confusion contributing to large variation in results and limiting their validity. Eight studies defined confusion using valid criteria; however, no studies defined UTI in accordance with established criteria. As no study used an acceptable definition of confusion and UTI, an association could not be reliably established. Only one study had acceptable definitions of confusion and bacteriuria, reporting an association with the relative risk being 1.4 (95% CI 1.0–1.7, p = 0.034).

Conclusions

Current evidence appears insufficient to accurately determine if UTI and confusion are associated, with estimates varying widely. This was often attributable to poor case definitions for UTI or confusion, or inadequate control of confounding factors. Future well-designed studies, using validated criteria for UTI and confusion are required to examine the relationship between UTI and acute confusion in the elderly. The optimal solution to clarify this clinical issue would be a randomized controlled trial comparing the effect of antibiotics versus placebo in patients with new onset or worsening confusion and presence of bacteriuria while lacking specific urinary tract symptoms.

Potentially avoidable hospitalisations of German nursing home patients? A cross-sectional study on utilisation patterns and potential consequences for healthcare

OBJECTIVES

Demand for nursing home (NH) care is soaring due to gains in life expectancy and people living longer with chronic illness and disability. This is dovetailing with workforce shortages across the healthcare profession. Access to timely and appropriate medical care for NH residents is becoming increasingly challenging and can result in potentially avoidable hospitalisations (PAHs). In light of these factors, we analysed PAHs comparing NH patients with non-NH patients.

DESIGN

Cross-sectional study with claims data from 2015 supplied by a large German health insurance company within the federal state of Baden-Wuerttemberg.

SETTING

One-year observation of hospitalisation patterns for NH and non-NH patients.

PARTICIPANTS

3 872 245 of the 10.5million inhabitants of Baden-Wuerttemberg were covered.

METHODS

Patient data about hospitalisation date, sex, age, nationality, level of care and diagnoses were available. PAHs were defined based on international classification of diseases (ICD-10) diagnoses belonging to ambulatory care sensitive conditions (ACSCs). Adjusted ORs for PAHs for NH patients in comparison with non-NH patients were calculated with multivariable regression models.

RESULTS

Of the 933 242 hospitalisations in 2015, there were 23 982 for 13 478 NH patients and 909 260 for 560 998 non-NH patients. Mean age of hospitalised NH patients and level of care were significantly higher than those of non-NH patients. 6449 PAHs (29.6%) for NH patients and 136 543 PAHs (15.02%) for non-NH patients were identified. The adjusted OR for PAHs was significantly heightened for NH patients in comparison with non-NH patients (OR: 1.22, CI (1.18 to 1.26), p<0.0001). Moreover, we could observe that more than 90% of PAHs with ACSCs were unplanned hospitalisations (UHs).

CONCLUSIONS

Large numbers of PAHs for NH patients calls for improved coordination of medical care, especially general practitioner service provision. Introduction of targeted training programmes for physicians and NH staff on health problem management for NH patients could perhaps contribute to reduction of PAHs, predominantly UHs.

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.

[Factors influencing the referral of nursing home patients to the hospital]

INTRODUCTION

Hospitalisation may cause negative effects on elderly patients. Therefore, it is important that referral and admission of older nursing home patients is well-considered. The aim of this study is to investigate the factors that affect the decision making process.

METHOD

Questionnaire survey among elderly care physicians and physicians following the elderly care physician training program.

RESULTS

Of the 1,540 surveys, 200 were returned (response rate of 13%). Over 60% of the respondents had referred a nursing home patient to the hospital in the previous month. A stay at a geriatric rehabilitation ward, suspicion of a fracture, a good quality of life, a patient's or family's wish for referral, no treatment restrictions, and follow-up appointments in the hospital were factors which made referral to the hospital more likely according to the respondents. Medical specialist consultation and the in hospital presence of a physician specialised in geriatric care were considered to be important. Referral was less likely if a patient was diagnosed with dementia, had a low quality of life or had treatment restrictions.

CONCLUSION

Both patient-related and non-patient-related factors influence hospital referral of nursing home patients. Further research is needed to determine whether these different factors contribute to the different outcomes of a hospital admission, to facilitate proper decision-making for elderly care physicians.

Organizational and environmental factors associated with transfers of nursing home residents to emergency departments

BACKGROUND/OBJECTIVES

The emergency department transfer (EDT) rate of residents from nursing homes (NHs) to emergency departments is an important public health issue. The purpose of this study was to examine whether organizational and geographical factors were associated with EDT among older adults living in NHs.

DESIGN

Retrospective analysis using information from patients' medical charts regarding hospitalization in the last 12 months. Information came from the baseline data of the IQUARE clinical trial.

PARTICIPANTS

5926 residents (86.0 years old, standard deviation, SD = 2.9), from 175 NHs with available data on EDT.

OUTCOME MEASURE

The EDT rate was estimated for each NH, from the number of residents who were transferred to an emergency department (one transfer or more) in the previous 12 months.

RESULTS

1119 (18.9%, SD = 11.5) residents were transferred to an emergency department at least once during the past year. In adjusted multiple linear regression, NHs located in rural areas had an EDT rate significantly lower than those in urban areas (confidence interval, 95% CI - 10.15, - 2.16, p = 0.003), with an absolute EDT rate of 16.4% (SD = 9.1) versus 20.4% (SD = 12.5); pharmacy for internal use was significantly associated with a lower EDT rate compared with the NHs with no PUI [11.9% (SD = 9.2); 19.1% (SD = 10.1), 95% CI - 16.33, - 3.09, p = 0.004] and the implementation of a personalized care project in NHs was significantly associated with a lower EDT rate [18.6% (SD = 11.4), 22.4% (SD = 12.4), 95% CI - 11.67, - 0.63, p = 0.03].

CONCLUSION

Our study suggests that a structured plan of care, a strategy to improve medication and being located in rural areas reduce the EDT rate in NH residents.

IQUARE STUDY TRIAL REGISTRATION NUMBER

NCT01703689.

A Composite of Functional Status and Pneumonia Severity Index Improves the Prediction of Pneumonia Mortality in Older Patients

BACKGROUND

The baseline health status may be a determinant of interest in the evolution of pneumonia.

OBJECTIVE

Our objective was to assess the predictive ability of community-acquired pneumonia (CAP) mortality by combining the Barthel Index (BI) and Pneumonia Severity Index (PSI) in patients aged ≥ 65 years.

DESIGN, PATIENTS AND MAIN MEASURES

In this prospective, observational, multicenter analysis of comorbidities, the clinical data, additional examinations and severity of CAP were measured by the PSI and functional status by the BI. Two multivariable models were generated: Model 1 including the PSI and BI and model 2 with PSI plus BI stratified categorically.

KEY RESULTS

The total population was 1919 patients, of whom 61% had severe pneumonia (PSI IV-V) and 40.4% had some degree of dependence (BI ≤ 90 points). Mortality in the PSI V-IV group was 12.5%. Some degree of dependence was associated with increased mortality in both the mild (7.2% vs. 3.2%; p = 0.016) and severe (14% vs. 3.3%; p < 0.001) pneumonia groups. The combination of PSI IV-V and BI ≤ 90 was the greatest risk factor for mortality (aOR 4.17; 95% CI 2.48 to 7.02) in our series.

CONCLUSIONS

The use of a bimodal model to assess CAP mortality (PSI + BI) provides more accurate prognostic information than the use of each index separately.

Telemedicine: Is it really worth it? A perspective from evidence and experience

BACKGROUND

 Although the formal evidence base is equivocal, practical experience suggests that implementations of technology that support telemedicine initiatives can result in improved patient outcomes, better patient and carer experience and reduced expenditure.

OBJECTIVE

To answer the questions "Is an investment in telemedicine worth it?" and "How do I make a telemedicine implementation work?"

METHODS

 Summary of systematic review evidence and an illustrative case study. Discussion of implications for industry and policy.

RESULTS

Realisation of telemedicine benefits is much less to do with the technology itself and much more around the context of the implementing organisation and its ability to implement.

CONCLUSION

 We recommend that local organisations consider deployment of telemedicine initiatives but with a greater awareness of the growing body of implementation best practice. We also recommend, for the NHS, that the centre takes a greater role in the collation and dissemination of best practice to support successful implementations of telemedicine and other health informatics initiatives.

Management of Nursing Home Residents Following Acute Hospitalization: Efficacy of the "Regular Early Assessment Post-Discharge (REAP)" Intervention

OBJECTIVES

Rehospitalization of nursing home (NH) residents is frequent, costly, potentially avoidable and associated with diminished quality of life and poor survival. This study aims to evaluate the impact and cost-effectiveness of the Regular Early Assessment Post-Discharge (REAP) protocol of coordinated specialist geriatrician and nurse practitioner visits on rates of rehospitalization, hospital length of stay, and emergency department presentations for NH residents recently discharged from hospital.

DESIGN

Prospective randomized controlled study of recently hospitalized NH residents.

SETTING

Twenty-one of 24 eligible NHs within the geographical catchment area of St George Hospital, a 650-bed university hospital in Sydney, Australia.

PARTICIPANTS

NH residents from eligible facilities admitted to St George Hospital's geriatric service were enrolled prior to hospital discharge.

INTERVENTION

REAP intervention of monthly coordinated specialist geriatrician and nurse practitioner assessments within participants' NHs for 6 months following hospital discharge.

MEASUREMENTS

Impact of the REAP intervention on hospital readmissions, hospital inpatient days, emergency department utilization, general practitioner visits, investigations and associated costs during the study intervention period.

RESULTS

Forty-three NH residents were randomly allocated to REAP intervention (n = 22) or control (n = 21) groups. The REAP intervention group had almost two-thirds fewer hospital readmissions (P = .03; Cohen's d = 0.73) and half as many emergency department visits than controls. Total costs were 50% lower in the REAP intervention group, with lower total hospital inpatient (P = .04; Cohen's d = 0.63) and total emergency department (P = .04; Cohen's d = 0.65) costs.

CONCLUSION

Cost-effective reductions in the utilization of hospital-related services were demonstrated following implementation of the REAP intervention for NH residents recently discharged from hospital.