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

Analysis of traumatic event emergency department visits among care home residents aged 65 + years in Southern Jutland, Denmark: implications for comprehensive care and subsequent hospital admissions - a register-based cohort study

BACKGROUND

Care home residents aged 65 + years frequently experience acute health issues, leading to emergency department visits. Falls and associated injuries are a common cause of these visits and falls in a geriatric population can be a symptom of an incipient acute illness such as infection. Conversely, the traumatic event can cause illnesses to arise due to consequences of the fall, e.g. delirium or constipation due to opioid use. We hypothesised that a traumatic event treat-and-release emergency department visit serves as an indicator for an upcoming acute hospital admission due to non-trauma-related conditions.

METHODS

We studied emergency department visits for traumatic events among all care home residents aged 65+ (n = 2601) living in Southern Jutland, Denmark, from 2018 to 2019. Data from highly valid national registers were used to evaluate diagnoses, mortality, and admissions. Cox Regression was used to analyse the hazard of acute hospital admission following an emergency department treat-and-release visit.

RESULTS

Most visits occurred on weekdays and during day shifts, and 72.0% were treated and released within 6 h. Contusions, open wounds, and femur fractures were the most common discharge diagnoses, accounting for 53.3% of all cases (n = 703). In-hospital mortality was 2.3%, and 30-day mortality was 10.4%. Among treat-and-release visits (n = 506), 25% resulted in a new hospital referral within 30 days, hereof 13% treat-and-release revisits (duration ≤ 6 h), and 12% hospital admissions (duration > 6 h). Over half (56%) of new hospital referrals were initiated within the first seven days of discharge. Almost three-fourths of subsequent admissions were caused by various diseases. The hazard ratio of acute hospital admissions was 2.20 (95% CI: 1.52-3.17) among residents with a recent traumatic event treat-and-release visit compared to residents with no recent traumatic event treat-and-release visit.

CONCLUSION

Traumatic event treat-and-release visits among care home residents serve as an indicator for subsequent hospitalisations, highlighting the need for a more comprehensive evaluation, even for minor injuries. These findings have implications for improving care, continuity, and resource utilisation.

TRIAL REGISTRATION

Not relevant.

Emergency department resource utilization among nursing home residents, a National Cross-Sectional Study

OBJECTIVES

Persons 65 years and older (older persons), particularly residents of nursing homes (NHs), disproportionately access the emergency department (ED) and utilize more medical resources. The goal of this study is to provide a contemporary description of healthcare utilization patterns and disposition decisions for United States (US) NH residents presenting to EDs.

METHODS

Older persons presenting to EDs in the US were identified in the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2017, 2018 and 2019 datasets. We examined demographic, clinical, and resource use characteristics and outcomes. After survey weighting, we compared the frequency of different imaging, medications, clinical interventions, and outcomes in the ED between NH residents and those residing outside NHs.

RESULTS

From 2017 to 2019, older persons made 24,441,285 annual visits to the ED, comprising 17.5% of all visits. Among these, 1,579,916 visits (6.5%) were by NH residents. Compared with non-NH residents, NH residents were older (mean age: 81.2 [95%CI 81.5-82.9] vs 76.1 [95%CI 75.8-76.4]), underwent more imaging (82.8% [95%CI 79.5-86.1] vs 71.6% [95%CI 69.9-73.3]), were administered fewer potentially inappropriate medications (PIMs) in the ED or upon discharge (9.5% [95%CI 6.2-2.7] vs 17.1% [95%CI 15.8-18.4]), and had a higher proportion of visits resulting in hospital admission (44.1% [95%CI 38.2-49.9] vs 26.0% [95%CI 23.3, 28.7]).

CONCLUSIONS

Older NH residents presenting to the ED use more resources and are more likely to be hospitalized compared to older persons residing outside NHs. The resource-intensive nature of these visits highlights the importance of targeted, multi-disciplinary interventions that optimize ED care for this population.

Internal Medicine Virtual Specialist Assessment Program Reduces Emergency Department Transfers from Long-Term Care

BACKGROUND

Transfers to emergency departments (EDs) from long-term care (LTC) can expose residents to care discontinuities and risks. Virtual platforms can increase the breadth of care available for residents within their facility, thus replacing transfers to EDs when safe and appropriate. The authors aimed to assess whether leveraging a virtual care platform at an LTC facility would reduce the number of transfers to EDs.

METHODS

Data on the number of transfers to EDs were collected from January 2019 to October 2021 at an LTC facility. In June 2020 the home began using a virtual care platform that allowed residents to speak with specialist physicians through video and receive management plans remotely. The authors evaluated the Internal Medicine Virtual Specialist Program (IMVSP) using a pre-post study design by comparing the number of transfers to EDs and the proportion of transfers resulting in hospital admission before and after program implementation. Unstructured phone interviews were conducted with employees at the home to understand their experiences.

RESULTS

The median number of transfers to EDs per month after program implementation showed a 13.0% reduction. The median proportion of these transfers resulting in hospital admission per month increased by 26.1%. Employees at the LTC home were satisfied with the program.

CONCLUSION

The IMVSP reduced transfers to EDs and allowed for a higher proportion of transfers that resulted in hospital admission. Early access to specialist care via virtual platforms has important implications for improving accessibility to high-quality care for LTC residents and reducing risks associated with transfers.

Nursing Home Residents With Dementia at End of Life: Emergency Department Visits, Hospitalizations, and Acute Hospital Deaths

Background: Most nursing home (NH) residents do not benefit from health care at an emergency room (ER) or inpatient care at an emergency hospital during the end-of-life period. Therefore, a low number of unplanned admissions during the last month of life are considered good quality of care. Objectives: This study examined ER visits, hospital admissions, and place of death in NH residents with and without dementia in the last month of life, with the aim of answering the question, "Are NH residents with dementia provided with equal health care in their last stage of life?" Design: An observational retrospective study of registry data from all NH residents who died during the years 2015-2019, using health care consumption data from the Stockholm Regional Council, Sweden. Results: Dementia was associated with a higher adjusted odds ratio (aOR) for ER visits (aOR 1.32, p < 0.0001) and acute admissions (aOR 1.30, p < 0.0001) (logistic regression, including sensitivity analysis). Being male, young, and having multiple comorbidities (Charlson Comorbidity Index) and frailty (Hospital Frailty Risk Score) were all independently associated with higher aORs for the same outcomes and also with hospital deaths. Conclusion: Dementia is associated with increased ER referrals and acute in-hospital care. Comorbidities and frailty were strongly associated with an increase in hospital deaths. In addition, men are sent to emergency hospitals more frequently than women, and older residents are sent to the hospital to a lesser extent than younger residents, which cannot be explained by the factors studied.

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.

Interprofessional relationships and their impact on resident hospitalizations in nursing homes: A qualitative study

AIM

The aim of this study is to explore experiences and perspectives of nurses and providers (e.g., physicians, medical directors, fellows, and nurse practitioners) on reducing preventable hospitalizations of nursing home (NH) residents in relation to interprofessional relationship and hospitalization decision-making process.

BACKGROUND

Preventable NH resident hospitalization continues to be a pressing public health issue. Studies show that improved interprofessional relationship may help reduce hospitalization, yet research on communication processes and interactions among different NH staff remains limited.

METHODS

This is a qualitative descriptive study. Two focus groups were held with fourteen nurses and thirteen in-depth, qualitative interviews were conducted with providers from two Chicagoland NHs. Focus group sessions and interviews were transcribed, coded, and analyzed for common themes based on qualitative description method.

RESULTS

All study participants agreed that providers have the ultimate responsibility for hospitalization decisions. However, nurses believed they could influence those decisions, depending on provider characteristics, trust, and resident conditions. Nurses and providers differed in the way they experienced and conveyed emotions, and differed in key elements affecting hospitalization decisions such as structural or environmental factors (e.g., lacking staff and equipment at the facility, poor communication between the NH and hospitals) and interpersonal factors (e.g., characteristics of effective nurses or providers and the effective interactions between them).

CONCLUSIONS

Interpersonal factors, including perceived competence, respect, and trust, may influence NH hospitalization decisions and be targeted for reducing preventable hospitalizations of residents.

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Epidemiology and clinical characteristics of trauma in older patients transferred from long-term care hospitals to emergency departments: A nationwide retrospective study in South Korea

BACKGROUND

South Korea's aging population had leg to an increased number of long-term care hospitals (LTCHs), and increased transfer of older patients to emergency departments (EDs). This study investigated the epidemiological and injury profiles of LTCH patients aged ≥65 who were transferred from LTCHs to EDs due to trauma.

METHOD

This retrospective study conducted between January 2014 and December 2019 in South Korea utilized data from the National Emergency Department Information System. The requirement for informed consent was waived by the IRB due to the retrospective nature of the study. Patient information was anonymized prior to analysis.

RESULTS

Of the 1,472,006 trauma cases aged ≥65, 14,469 came from LTCHs. Outcomes varied: 44.1% were discharged, 40.6% were admitted to general wards (GW), 5.9% to intensive care units (ICU), 2.4% to other hospitals, and 6.5% returned to LTCHs. ED length of stay (LOS) was longest in the death (410.28 ± 559.73 min) and GW admission (390.12 ± 621.71 min) groups. Falls were the main cause of injury (50.1%), and the most common fracture was femoral (71.6%). Femoral and shoulder/upper extremity fractures increased hospitalization risk only, whereas self-harm increased both hospitalization and mortality risk.

CONCLUSION

Visits to the ED by older patients from LTCH for trauma were avoidable in 50.6% of cases. Additionally, these patients had longer ED LOS and higher hospitalization rates than non-LTCH patients. Falls were the predominant mode of presentation, femoral fracture was the most common fracture among patients from LTCH.

Rates of 30-day revisit to the emergency department among older adults living with dementia: a systematic review and meta-analysis

OBJECTIVE

Older adults visit emergency departments (EDs) at higher rates than their younger counterparts. However, less is known about the rate at which older adults living with dementia visit and revisit EDs. We conducted a systematic review and meta-analysis to quantify the revisit rate to the ED among older adults living with a dementia diagnosis.

METHODS

We searched MEDLINE, Embase, and CINAHL, as well as gray literature, to identify observational studies reporting on older adults living with dementia that revisited an ED within 30 days of a prior ED visit. We calculated pooled rates of 30-day revisit as percentages using random effects models, and conducted stratified analyses by study data source, study population, and study period. We assessed between-studies heterogeneity using the I2 statistic and considered [Formula: see text] > 50% to indicate substantial heterogeneity. All analyses were performed in R software.

RESULTS

We identified six articles for inclusion. Percentages of 30-day ED revisit among older adults living with dementia ranged widely from 16.1% to 58.0%. The overall revisit rate of 28.6% showed significant heterogeneity. Between-studies heterogeneity across all stratified analyses was also high. By data source, 30-day revisit percentages were 52.3% (public hospitals) and 20.0% (administrative databases); by study population, revisit percentages were 33.5% (dementia as main population) and 19.8% (dementia as a subgroup). By study period, revisit percentages were 41.2% (5 years or greater) and 18.9% (5 years or less).

CONCLUSION

Existing literature on ED revisits among older adults living with dementia highlights the medical complexities and challenges surrounding discharge and follow-up care that may cause these patients to seek ED care at an increased rate. ED personnel may play an important role in connecting patients and caregivers to more appropriate medical and social resources in order to deliver an efficient and more rounded approach to care.

The hospital care and outcomes of long-term care patients treated by paramedics during an emergency call: exploring the potential impact of 'treat-and-refer' pathways and community paramedicine

INTRODUCTION

Adults living in long-term care (LTC) are at increased risk of harm when transferred to the emergency department (ED), and programs targeting treatment on-site are increasing. We examined characteristics, clinical course, and disposition of LTC patients transported to the ED to examine the potential impact of alternative models of paramedic care for LTC patients.

METHODS

We conducted a health records review of paramedic and ED records between April 1, 2016, and March 31, 2017. We included emergency calls originating from LTC centers and patients transported to either ED campus of The Ottawa Hospital. We excluded scheduled or deferrable transfers, and patients with Canadian Triage and Acuity Scale of 1. We categorized patients into groups based on care they received in the ED. We calculated standardized differences to examine differences between groups.

RESULTS

We identified four groups: (1) patients requiring no treatment or diagnostics in the ED (7.9%); (2) patients receiving ED treatment within current paramedic directives and no diagnostics (3.2%); (3) patients requiring diagnostics or ED care outside current paramedic directives (54.9%); and (4) patients requiring admission (34.1%).

CONCLUSION

This study found 7.9% of LTC patients transported to the ED did not receive diagnostics, medications, or treatment, and overall 11.1% of patients could have been treated by paramedics within current medical directives using 'treat-and-refer' pathways. This group could potentially expand utilizing community paramedics with expanded scopes of practice.

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.

Measuring Potentially Avoidable Acute Care Transfers From Long-Term Care Homes in Quebec: a Cross Sectional Study

Background

Potentially avoidable emergency department transfers (PAEDTs) and hospitalizations (PAHs) from long-term care (LTC) homes are two key quality improvement metrics. We aimed to: 1) Measure proportions of PAEDTs and PAHs in a Quebec sample; and 2) Compare them with those reported for the rest of Canada.

Methods

We conducted a repeated cross-sectional study of residents who were received at one tertiary hospital between April 2017 and March 2019 from seven LTC homes in Quebec, Canada. The MedUrge emergency department database was used to extract transfers and resident characteristics. Using published definitions, PAEDTs and PAHs were identified from principal emergency department and hospitalization diagnoses, respectively. PAEDT and PAH proportions were compared to those reported by the Canadian Institute for Health Information.

Results

A total of 1,233 transfers by 692 residents were recorded, among which 36.3% were classified as being potentially avoidable: 22.8% 'PAEDT only', 11.6% 'both PAEDT & PAH', and 1.9% 'PAH only'. Shortness of breath was the most common reason for transfer. Pneumonia was the most common diagnosis from the 'both PAEDT & PAH' category. PAEDTs and PAHs accounted for 95% and 37% of potentially avoidable transfers, respectively. Among 533 hospitalizations, 31.3% were PAHs. These proportions were comparable to the rest of Canada, with some differences in proportions of transfers due to congestive heart failure, urinary tract infection, and implanted device management.

Conclusions

PAEDTs far outweigh PAHs in terms of frequency, and their monitoring is important for quality assurance as they may inform LTC-level interventions aimed at their reduction.

Emergency department visits and associated factors among people with dementia residing in nursing homes in Taiwan: a one-year cohort study

BACKGROUND

Residing in a nursing home (NH) may increase emergency department (ED) utilization in patients with dementia; however, evidence regarding the status of and predictors for ED utilization of NH residents with dementia remains unclear, especially in Asia. This study aimed to assess the incidence density of ED visits and associated factors for the risk of ED utilization among NH residents with dementia.

METHODS

This one-year cohort study followed 6595 NH residents with dementia aged ≧ 40 years from Taiwan's National Health Insurance Research Database between 2012 and 2014. The Andersen-Gill extension of Cox regression analysis with death as a competing risk was applied to investigate the association of the risk of all causes and the most common causes of ED utilization with the predisposing, enabling, and need factors as defined by the Andersen model.

RESULTS

All participants encountered 9254 emergency visits in the 5371.49 person-years observed, representing incidence densities of ED visits of 1722.80 per 1000 person-years. Among them, respiratory disease was the most common cause of ED visits. The significant predictors for the risk of all-cause and respiratory-cause ED visits included: (1) predisposing factors (i.e., age and gender); (2) enabling factors (i.e., regional variables); and (3) need factors (i.e., prolonged ventilator dependence and comorbidity status).

CONCLUSIONS

Predisposing, enabling, and need factors could influence ED visits among studies patients. NH providers should consider these factors to develop strategies for reducing ED utilization.

Association of topical glaucoma medications with lacrimal drainage obstruction and eyelid malposition

BACKGROUND/OBJECTIVES

Adverse effects of topical glaucoma medications (TGMs) may include development of ocular adnexal disorders. We undertook a study to determine the effect of TGMs on the risk of developing lacrimal drainage obstruction (LDO) and eyelid malposition.

SUBJECTS/METHODS

All patients 66 years of age and older in Ontario, Canada initiating TGM and all patients diagnosed with glaucoma/suspected glaucoma but not receiving TGM from 2002 to 2018 were eligible for inclusion in this retrospective cohort study. Using validated healthcare administrative databases, cohorts were identified with TGM and no TGM patients matched 1:2 on sex and birth year. The effect of TGM treatment on risk of surgery for LDO and lid malpositions was estimated using Kaplan-Meier and Cox proportional hazards models.

RESULTS

Cohorts included 122,582 patients in the TGM cohort and 232,336 patients in the no TGM cohort. Among the TGM cohort there was decreased event-free survival for entropion (log-rank P < 0.001), trichiasis (P < 0.001), and LDO (P = 0.006), and increased ectropion-free survival (P = 0.007). No difference in ptosis-free survival was detected (P = 0.78). For the TGM cohort there were increased hazards for entropion (hazard ratio [HR] 1.24, 95% confidence interval [CI] 1.12-1.37; P < 0.001), trichiasis (HR 1.74, 95% CI 1.57-1.94; P < 0.001), and LDO (at 15 years: HR 2.39, 95% CI 1.49-3.85; P = 0.004), and a decreased hazard for ectropion (HR 0.89, 95% CI 0.81-0.97; P = 0.008). No association between TGM treatment and ptosis hazard was detected (HR 0.99, 95% CI 0.89-1.09; P = 0.78).

CONCLUSIONS

TGMs are associated with an increased risk of undergoing surgery for LDO, entropion, and trichiasis.

Associations between care home residents' characteristics and acute hospital admissions - a retrospective, register-based cross-sectional study

BACKGROUND

Care home residents are frail, multi-morbid, and have an increased risk of experiencing acute hospitalisations and adverse events. This study contributes to the discussion on preventing acute admissions from care homes. We aim to describe the residents' health characteristics, survival after care home admission, contacts with the secondary health care system, patterns of admissions, and factors associated with acute hospital admissions.

METHOD

Data on all care home residents aged 65 + years living in Southern Jutland in 2018-2019 (n = 2601) was enriched with data from highly valid Danish national health registries to obtain information on characteristics and hospitalisations. Characteristics of care home residents were assessed by sex and age group. Factors associated with acute admissions were analysed using Cox Regression.

RESULTS

Most care home residents were women (65.6%). Male residents were younger at the time of care home admission (mean 80.6 vs. 83.7 years), had a higher prevalence of morbidities, and shorter survival after care home admission. The 1-year survival was 60.8% and 72.3% for males and females, respectively. Median survival was 17.9 months and 25.9 months for males and females, respectively. The mean rate of acute hospitalisations was 0.56 per resident-year. One in four (24.4%) care home residents were discharged from the hospital within 24 h. The same proportion was readmitted within 30 days of discharge (24.6%). Admission-related mortality was 10.9% in-hospital and 13.0% 30 days post-discharge. Male sex was associated with acute hospital admissions, as was a medical history of various cardiovascular diseases, cancer, chronic obstructive pulmonary disease, and osteoporosis. In contrast, a medical history of dementia was associated with fewer acute admissions.

CONCLUSION

This study highlights some of the major characteristics of care home residents and their acute hospitalisations and contributes to the ongoing discussion on improving or preventing acute admissions from care homes.

TRIAL REGISTRATION

Not relevant.

Noticing Acute Changes in Health in Long-Term Care Residents

PURPOSE

Early signs of acute conditions and increased fall risk often go unrecognized in patients in long-term care facilities. The aim of this study was to examine how healthcare staff identify and act on changes in health status in this patient population.

DESIGN

A qualitative study design was used for this study.

METHODS

Six focus groups across two Department of Veterans Affairs long-term care facilities were conducted with 26 interdisciplinary healthcare staff members. Using thematic content analysis, the team preliminarily coded based on interview questions, reviewed and discussed emerging themes, and agreed on the resultant coding scheme for each category with additional independent scientist review.

RESULTS

Themes included describing and explaining how "normal" or expected behavior is identified by staff, noticing changes in a resident, determining the significance of the change, hypothesizing reasons for an observed change, response to an observed change, and resolution of the clinical change.

CONCLUSIONS

Despite limited training in formal assessment methods, long-term care staff have developed methods to conduct ongoing assessments of the residents. This technique, individual phenotyping, often identifies acute changes; however, the lack of formal methods, language, or tools to communicate the changes means that these assessments are not often formalized in a manner that informs the residents' changing care needs.

CLINICAL RELEVANCE TO THE PRACTICE OF REHABILITATION NURSING

More formal objective measures of health change are needed to assist long-term care staff in expressing and interpreting the subjective phenotype changes into objective, easily communicated health status changes. This is particularly important for acute health changes and impending falls, both of which are associated with acute hospitalization.

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.

Examining the "Potentially Preventable Emergency Department Transfer" Indicator Among Nursing Home Residents

OBJECTIVE

To determine if nursing home (NH) resident characteristics associated with potentially preventable emergency department transfers (PPEDs) are similarly associated with non-potentially preventable emergency department transfers (non-PPEDs).

DESIGN

We conducted a population-level retrospective cohort study using linked administrative data reported using the Resident Assessment Instrument-Minimum Data Set Version 2.0 and the National Ambulatory Care Reporting System for emergency department transfers.

SETTING AND PARTICIPANTS

We assessed all NH residents transferred to the emergency department within 92 days after admission. The cohort included 56,433 NH resident admissions assessment of which 3498 NH residents experienced PPEDs, and 9331 residents experienced non-PPEDs.

METHODS

We assessed Ontario NH residents admission assessments collected between January 1, 2017, and December 31, 2018. We used cumulative incidence functions and Cox regression to compare resident characteristics between residents experiencing PPEDs and non-PPEDs. PPEDs were defined based on the International Classification of Diseases, 10th Revision.

RESULTS

Approximately 23% of residents experienced an emergency department transfer within 92 days of NH admission. The cumulative incidence of PPEDs was 6.3% and non-PPEDs was 16.8%. After adjusting for clinically relevant features, 14 of 18 resident admission characteristics were associated with both types of transfers. Resident admission characteristics associated with a greater risk of PPEDs solely were pneumonia [hazard ratio (HR) 1.48; CI 1.25-1.70] and oxygen therapy (HR 1.88; CI 1.69-2.10). Resident admission characteristics associated with a greater risk of non-PPEDs solely are experiencing a change in mood (HR 1.09; CI 1.01-1.18) and delirium (HR 1.08; CI 1.04-1.13).

CONCLUSIONS AND IMPLICATIONS

PPEDs were associated with a similar cluster of NH resident characteristics as those transferred for non-ambulatory reasons, suggesting that the clinical distinction between PPEDs vs non-PPEDs within the NH might be unclear. These findings highlight that the PPED indicator could be revised to improve specificity.

Inclusion of patient-level emergency department characteristics to classify potentially redirectable visits to subacute care: a modified Delphi consensus study

BACKGROUND

Most patients transported by Ontario paramedics to the emergency department have non-emergent conditions and may be more appropriately served by subacute community-based care centres. We sought to determine consensus on a set of patient characteristics that could be useful to classify retrospective emergency department visits that had a high probability of being primary care-like and potentially redirectable to a subacute care centre by paramedics.

METHODS

We conducted a modified Delphi study to assess expert consensus on characteristics of patients transported by paramedics to the emergency department from August to October 2021. An expert Delphi committee was constructed of emergency and family physicians in Ontario using purposive sampling. Experts rated whether each characteristic was useful to be included in a classification to identify potentially redirectable visits retrospectively, as well as characteristic details (e.g., upper and lower bounds). Consensus was considered 75% agreement.

RESULTS

Sixteen experts participated in the study; the experts were mostly male (75%) and evenly divided between emergency and family medicine. After 2 rounds, consensus was achieved on 8 of 9 characteristics (89%). Four characteristics were determined as useful to classify potentially redirectable emergency department visits: age (81%), triage acuity (100%), specialist consult in the emergency department (94%) and emergency department visit outcome (81%). Specifications of each characteristic were refined as follows: young and middle-aged adults with a non-emergent triage acuity, did not receive a specialist physician consult in the emergency department and discharged from the emergency department.

INTERPRETATION

Strong consensus was achieved to specify a classification system for potentially redirectable emergency department visits. These results will be combined with knowledge of which subacute care centres could conduct the main physician interventions to retrospectively identify emergency department visits that could have been suitable for paramedic redirection for further research.

STUDY REGISTRATION

ID ISRCTN22901977.

Emergency Department Visits Before, After and During Integrated Home Care: A Time Series Analyses in Italy

BACKGROUND

Integrated home care (IHC) is one strategy to provide care to people with multiple chronic conditions, and it contributes to the reduction of unnecessary emergency department (ED) use, but there are conflicting results on its effectiveness. In this study, we assessed the frequency and characteristics of ED visits occurring before, during, and after IHC in a large cohort of IHC patients enrolled over 6 years.

METHODS

The analysis included 39 822 IHC patients identified in Italian administrative databases. Patients were grouped in tertiles according to IHC duration (short, intermediate, and long) and the number of ED visits during IHC was compared to that the 12 months before IHC enrolment and in the 12 months after IHC discharge across IHC duration groups.

RESULTS

We observed a reduction in ED visits during IHC. IHC was significantly associated with a reduction in ED visits in the long and short IHC duration groups. A non-significant reduction in ED visits was observed in the intermediate IHC duration group. A 90% reduction in ED visits during IHC and a 45% reduction after IHC was observed in the short IHC duration group. Corresponding reductions were 17% and 64% during and after IHC, respectively, in the long IHC duration group.

CONCLUSION

IHC was effective in reducing ED visits, but expansion of IHC to include additional necessary services could further reduce ED visits. Investment in the creation of a structured, effective network of engaged professionals (including community care services and hospitals) is crucial to achieving this.

Validation of a classification to identify emergency department visits suitable for subacute and virtual care models: a randomised single-blinded agreement study protocol

INTRODUCTION

Redirecting suitable patients from the emergency department (ED) to alternative subacute settings may assist in reducing ED overcrowding while delivering equivalent care. The Emergency Department Avoidance Classification (EDAC) was constructed to retrospectively classify ED visits that may have been suitable for safe management in a subacute or virtual clinical setting. The EDAC has established face and content validity but has not been tested against a reference standard as a criterion.

OBJECTIVES

Our primary objective is to examine the agreement between the EDAC and ED physician judgements in retrospectively identifying ED visits suitable for subacute care management. Our secondary objective is to assess the validity of ED physicians' judgement as a criterion standard. Our tertiary objective is to examine how the ED physician's perception of a virtual ED care alternative correlates with the EDAC.

METHODS AND ANALYSIS

A randomised single-centre, single-blinded agreement study. We will randomly select ED charts between 1 January and 31 December 2019 from an academic hospital in Hamilton, Canada. ED charts will be randomly assigned to participating ED physicians who will evaluate if this ED visit could have been managed appropriately and safely in a subacute and/or virtual model of care. Each chart will be reviewed by two physicians independently. We compute our needed sample size to be 79 charts. We will use kappa statistics to measure inter-rater agreement. A repeated measures regression model of physician ratings will provide variance estimates that we will use to assess the intraclass correlation of ED physician ratings and the EDAC.

ETHICS AND DISSEMINATION

This study has been approved by the Hamilton Integrated Research Ethics Board (2022-14625). If validated, the EDAC may provide an ED-based classification to identify potentially avoidable ED visits, monitor ED visit trends, and proactively delineate those best suited for subacute or virtual care models.

Does the definition of preventable emergency department visit matter? An empirical analysis using 20 million visits in Ontario and Alberta

OBJECTIVES

This study had two objectives: (1) to estimate the prevalence of preventable emergency department (ED) visits during the 2016-2020 time period among those living in 19 large urban centers in Alberta and Ontario, Canada, and (2) to assess if the definition of preventable ED visits matters in estimating the prevalence.

METHODS

A retrospective, population-based study of ED visits that were reported to the National Ambulatory Care Reporting System from April 1, 2016, to March 31, 2020, was conducted. Preventable ED visits were operationalized based on the following approaches: (1) Canadian Triage and Acuity Scale (CTAS), (2) ambulatory care-sensitive conditions (ACSC), (3) family practice-sensitive conditions (FPSC), and (4) sentinel nonurgent conditions (SNC). The overall proportion of ED visits that were preventable was estimated. We also estimated the adjusted relative risks of preventable ED visits by patients' sex and age, fiscal year, province of residence, and census metropolitan area (CMA) of residence.

RESULTS

There were 20,171,319 ED visits made by 8,919,618 patients ages 1 to 74 who resided in one of the 19 CMAs in Alberta or Ontario. On average, there were 2.26 visits per patient over the period of 4 fiscal years; most patients made one (44.22%) or two ED visits (20.72%). The overall unadjusted prevalence of preventable ED visits varied by definition; 35.33% of ED visits were defined as preventable based on CTAS, 12.88% based on FPSC, 3.41% based on SNC, and 2.33% based on ACSC.

CONCLUSIONS

There is a substantial level of variation in prevalence estimates across definitions of preventable ED visits, and care should be taken when interpreting these estimates as each has a different meaning and may lead to different conclusions. The conceptualization and measurement of preventable ED visits is complex and multifaceted and may not be adequately captured by a single definition.

Emergency department transfers from residential aged care: what can we learn from secondary qualitative analysis of Australian Royal Commission data?

OBJECTIVES

To use publicly available submissions and evidence from the Australian Royal Commission into Aged Care Quality and Safety as data for secondary qualitative analysis. By investigating the topic of emergency department transfer from the perspective of residents, family members and healthcare professionals, we aimed to identify modifiable factors to reduce transfer rates and improve quality of care.

DESIGN

The Australian Royal Commission into Aged Care Quality and Safety has made over 7000 documents publicly available. We used the documents as a large data corpus from which we extracted a data set specific to our topic using keywords. The analysis focused on submissions and hearing transcripts (including exhibits). Qualitative thematic analysis was used to interrogate the text to determine what could be learnt about transfer events from a scholarly perspective.

RESULTS

Three overarching themes were identified: shortfalls and failings, reluctance and misunderstanding, and discovery and exposure.

CONCLUSIONS

The results speak to workforce inadequacies that have been central to problems in the Australian aged care sector to date. We identified issues around clinical and pain assessment, lack of consideration to advance care directives and poor communication among all parties. We also highlighted the role that emergency departments play in identifying unmet clinical needs, substandard care and neglect. Given the inadequate clinical care available in some residential aged care facilities, transferring residents to a hospital emergency department may be making the best of a bad situation. If the objective of reducing unnecessary transfers to emergency departments is to be achieved, then access to appropriate clinical care is the first step.

An analysis of a novel Canadian pilot health information exchange to improve transitions between hospital and long-term care/skilled nursing facility

Purpose

The purpose of the article is to assess the effectiveness, compliance, adoption and lessons learnt from the pilot implementation of a data integration solution between an acute care hospital information system (HIS) and a long-term care (LTC) home electronic medical record through a case report.

Design/methodology/approach

Utilization statistics of the data integration solution were captured at one-month post implementation and again one year later for both the emergency department (ED) and LTC home. Clinician feedback from surveys and structured interviews was obtained from ED physicians and a multidisciplinary LTC group.

Findings

The authors successfully exchanged health information between a HIS and the electronic medical record (EMR) of an LTC facility in Canada. Perceived time savings were acknowledged by ED physicians, and actual time savings as high as 45 min were reported by LTC staff when completing medication reconciliation. Barriers to adoption included awareness, training efficacy and delivery models, workflow integration within existing practice and the limited number of facilities participating in the pilot. Future direction includes broader staff involvement, expanding the number of sites and re-evaluating impacts.

Practical implications

A data integration solution to exchange clinical information can make patient transfers more efficient, reduce data transcription errors, and improve the visibility of essential patient information across the continuum of care.

Originality/value

Although there has been a large effort to integrate health data across care levels in the United States and internationally, the groundwork for such integrations between interoperable systems has only just begun in Canada. The implementation of the integration between an enterprise LTC electronic medical record system and an HIS described herein is the first of its kind in Canada. Benefits and lessons learnt from this pilot will be useful for further hospital-to-LTC home interoperability work.

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.

Clinical factors associated with recent medical care visits in nursing homes: a multi-site cross-sectional study

Objectives

We examined which resident-level clinical factors influence the provision of a recent medical care visit in nursing homes (NHs).

Design

Multi-site cross-sectional.

Setting and participants

We extracted data on 3,556 NH residents from 18 NH facilities in Ontario, Canada, who received at minimum, an admission and first-quarterly assessment with the Resident Assessment Instrument Minimum Data Set (MDS) 2.0 between November 1, 2009, and October 31, 2017.

Methods

We conducted a secondary analysis of routinely collected MDS 2.0 data. The provision of a recent medical care visit by a physician (or authorized clinician) was assessed in the 14-day period preceding a resident’s first-quarterly MDS 2.0 assessment. We utilized best-subset multivariable logistic regression to model the adjusted associations between resident-level clinical factors and a recent medical care visit.

Results

Two thousand eight hundred fifty nine (80.4%) NH residents had one or more medical care visits prior to their first-quarterly MDS 2.0 assessment. Six clinically relevant factors were identified to be associated with recent medical care visits in the final model: exhibiting wandering behaviours (OR = 1.34, 95% CI 1.09 – 1.63), presence of a pressure ulcer (OR = 1.37, 95% CI 1.05 – 1.78), a urinary tract infection (UTI) (OR = 1.52, 95% CI 1.06 – 2.18), end-stage disease (OR = 9.70, 95% CI 1.32 – 71.02), new medication use (OR = 1.31, 95% CI 1.09 – 1.57), and analgesic use (OR = 1.24, 95% CI 1.03 – 1.49).

Conclusions and implications

Our findings suggest that resident-level clinical factors drive the provision of medical care visits following NH admission. Clinical factors associated with medical care visits align with the minimum competencies expected of physicians in NH practice, including managing safety risks, infections, medications, and death. Ensuring that NH physicians have opportunities to acquire and strengthen these competencies may be transformative to meet the ongoing needs of NH residents.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03011-9.

Behavioral Nudges to Improve Audit and Feedback Report Opening among Antibiotic Prescribers: A Randomized Controlled Trial

Background

Peer comparison audit and feedback has demonstrated effectiveness in improving antibiotic prescribing practices, but only a minority of prescribers view their reports. We rigorously tested three behavioral nudging techniques delivered by email to improve report opening.

Methods

We conducted a pragmatic randomized controlled trial among Ontario long-term care (LTC) prescribers enrolled in an ongoing peer comparison audit and feedback program which includes data on their antibiotic prescribing patterns. Physicians were randomized to 1 of 8 possible sequences of intervention/control allocation to 3 different behavioral email nudges: a social peer comparison nudge (January 2020), a maintenance of professional certification incentive nudge (October 2020), and a prior participation nudge (January 2021). The primary outcome was feedback report opening; the primary analysis pooled the effects of all 3 nudging interventions.

Results

The trial included 421 physicians caring for more than 28,000 residents at 450 facilities. In the pooled analysis, physicians opened only 29.6% of intervention and 23.9% of control reports (odds ratio (OR) 1.51 (95%CI 1.10-2.07, p=0.011); this difference remained significant after accounting for physician characteristics and clustering (adjusted OR (aOR) 1.74 (95%CI 1.24-2.45, p=0.0014). Of individual nudging techniques, the prior participation nudge was associated with a significant increase in report opening (OR 1.62, 95%CI 1.06-2.47, p=0.026; aOR 2.16, 95%CI 1.33-3.50, p=0.0018). In the pooled analysis, nudges were also associated with accessing more report pages (aOR 1.28, 95%CI 1.14-1.43, p&lt;0.001).

Conclusions

Enhanced nudging strategies modestly improved report opening, but more work is needed to optimize physician engagement with audit and feedback.

Identifying patient characteristics associated with potentially redirectable paramedic transported emergency department visits in Ontario, Canada: a population-based cohort study

OBJECTIVE

Paramedic redirection from emergency department (ED) to subacute centres may be more beneficial for some patients, though little is known about which patients are potentially appropriate. We examined whether patient characteristics were associated with ED visits when the main intervention was suitable to be performed in a subacute centre.

METHODS

We conducted a retrospective observational study using the National Ambulatory Care Reporting System from 2014 to 2018 in Ontario, Canada. We included all adult patients transported by paramedics and had a main physician intervention recorded. We used results of a RAND/UCLA modified Delphi study to categorise patients into either ED or a subacute care (urgent care and/or general practice centre) based on their main intervention. An independent logistic regression model was analysed for each subacute centre.

RESULTS

A total of 2 394 072 ED visits were included; 59% of ED interventions were categorised as 'urgent care', 27% 'ED only', 9% either 'urgent care' or 'general practice' and 5% had an intervention not previously classified. ED visits suitable for 'general practice' had the highest percentage of patients discharged, while 'ED only' had the lowest. Lower medical acuity, younger age, time of triage in evening and overnight, and discharged from ED were independently associated with both subacute centres. 'Urgent care' visits/interventions were associated with an ED main diagnosis of the respiratory system (OR 3.49), while 'general practice' visits were associated with mental health disorders (OR 9.85) and injury/poison/consequences of external causes (OR 3.38).

CONCLUSIONS

The majority of ED visits had a main intervention that could have potentially been conducted in a subacute centre. We identified characteristics and diagnostic patterns associated with ED visits when the main intervention was categorised as a subacute centre intervention. This study contributes knowledge to inform which patients are potentially appropriate for paramedic redirection.

Nursing Home Resident Admission Characteristics and Potentially Preventable Emergency Department Transfers

OBJECTIVES

To determine which nursing home (NH) resident-level admission characteristics are associated with potentially preventable emergency department (PPED) transfers.

DESIGN

We conducted a population-level retrospective cohort study on NH resident data collected using the Resident Assessment Instrument-Minimum Data Set Version 2.0 and linked to the National Ambulatory Care Reporting System for ED transfers.

SETTING

We used all NH resident admission assessments from January 1, 2017, to December 31, 2018, in Ontario.

PARTICIPANTS

The cohort included the admission assessment of 56,433 NH residents.

METHODS

PPED transfers were defined based on the International Classification of Disease, Version 10 (Canadian) We used logistic regression with 10-fold cross-validation and computed average marginal effects to identify the association between resident characteristics at NH admission and PPED transfers within 92 days after admission.

RESULTS

Overall, 6.2% of residents had at least 1 PPED transfer within 92 days of NH admission. After adjustment, variables that had a prevalence of 10% or more that were associated with a 1% or more absolute increase in the risk of a PPED transfer included polypharmacy [of cohort (OC) 84.4%, risk difference (RD) 2.0%], congestive heart failure (OC 29.0%, RD 3.0%), and renal failure (OC 11.6%, RD 1.2%). Female sex (OC 63.2%, RD -1.3%), a do not hospitalize directive (OC 24.4%, RD -2.6%), change in mood (OC 66.9%, RD -1.2%), and Alzheimer's or dementia (OC 62.1%, RD -1.2%) were more than 10% prevalent and associated with a 1% or more absolute decrease in the risk of a PPED.

CONCLUSIONS AND IMPLICATIONS

Though many routinely collected resident characteristics were associated with a PPED transfer, the absence of sufficiently discriminating characteristics suggests that emergency department visits by NH residents are multifactorial and difficult to predict. Future studies should assess the clinical utility of risk factor identification to prevent transfers.

Population-Wide Peer Comparison Audit and Feedback to Reduce Antibiotic Initiation and Duration in Long-Term Care Facilities with Embedded Randomized Controlled Trial

BACKGROUND

Antibiotic overprescribing in long-term care settings is driven by prescriber preferences and is associated with preventable harms for residents. We aimed to determine whether peer comparison audit and feedback reporting for physicians reduces antibiotic overprescribing among residents.

METHODS

We employed a province wide, difference-in-differences study of antibiotic prescribing audit and feedback, with an embedded pragmatic randomized controlled trial (RCT) across all long-term care facilities in Ontario, Canada, in 2019. The study year included 1238 physicians caring for 96 185 residents. In total, 895 (72%) physicians received no feedback; 343 (28%) were enrolled to receive audit and feedback and randomized 1:1 to static or dynamic reports. The primary outcomes were proportion of residents initiated on an antibiotic and proportion of antibiotics prolonged beyond 7 days per quarter.

RESULTS

Among all residents, between the first quarter of 2018 and last quarter of 2019, there were temporal declines in antibiotic initiation (28.4% to 21.3%) and prolonged duration (34.4% to 29.0%). Difference-in-differences analysis confirmed that feedback was associated with a greater decline in prolonged antibiotics (adjusted difference -2.65%, 95% confidence interval [CI]: -4.93 to -.28%, P = .026), but there was no significant difference in antibiotic initiation. The reduction in antibiotic durations was associated with 335 912 fewer days of treatment. The embedded RCT detected no differences in outcomes between the dynamic and static reports.

CONCLUSIONS

Peer comparison audit and feedback is a pragmatic intervention that can generate small relative reductions in the use of antibiotics for prolonged durations that translate to large reductions in antibiotic days of treatment across populations. Clinical Trials Registration. NCT03807466.

Injury-Related Emergency Department Presentations Among Residential Aged Care Residents in Victoria, Australia

OBJECTIVE

This study aimed to quantify and describe the characteristics of emergency department (ED) injury presentations and subsequent hospital admissions among residents of residential aged-care facilities (RACFs) in Victoria, Australia between 2008 and 2018.

METHODS

This study comprised a single jurisdiction population-based study of consecutive injury-related ED presentations of RACFs residents using the Victorian Emergency Minimum Dataset (VEMD).

RESULTS

The rate of ED injury presentations per 100,000 population decreased by .8% per year over 10 years (P = .03); however, the rate per 100,000 RACF bed days increased by .6% per year (P = .05). The proportion of presentations subsequently admitted to hospital increased 4.0% per year (P<.0001). The majority of presentations were due to falls (82.5%), with fracture(s) being the most common injury type (34.0%).

DISCUSSION

The increased rate of ED visits and hospital admissions in RACFs residents highlights the need to design specialized emergency care services and/or provide better direct access to hospital care for this vulnerable population.

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.

Background rates of all-cause mortality, hospitalizations, and emergency department visits among nursing home residents in Ontario, Canada to inform COVID-19 vaccine safety assessments

Background

Nursing home (NH) residents are prioritized for COVID-19 vaccination. We report monthly mortality, hospitalizations, and emergency department (ED) visit incidence rates (IRs) during 2010–2020 to provide context for COVID-19 vaccine safety assessments.

Methods

We observed outcomes among all NH residents in Ontario using administrative databases. IRs were calculated by month, sex, and age group. Comparisons between months were assessed using one-sample t-tests; comparisons by age and sex were assessed using chi-squared tests.

Results

From 2010 to 2019, there were 83,453 (SD: 652.4) NH residents per month, with an average of 2.3 (SD: 0.28) deaths, 3.1 (SD: 0.16) hospitalizations, and 3.6 (SD: 0.17) ED visits per 100 residents per month. From March to December 2020, mortality IRs were increased, but hospitalization and ED visit IRs were reduced (p < 0.05).

Conclusion

We identified consistent monthly mortality, hospitalization, and ED visit IRs during 2010–2019. Marked differences in these rates were observed during 2020, coinciding with the COVID-19 pandemic.

Factors Associated With Emergency Department Visits by People With Dementia Near the End of Life: A Systematic Review

OBJECTIVES

Emergency department (ED) attendance is common among people with dementia and increases toward the end of life. The aim was to systematically review factors associated with ED attendance among people with dementia approaching the end of life.

DESIGN

Systematic search of 6 databases (MEDLINE, EMBASE, ASSIA, CINAHL, PsycINFO, and Web of Science) and gray literature. Quantitative studies of any design were eligible. Newcastle-Ottawa Scales and Cochrane risk-of-bias tools assessed study quality. Extracted data were reported narratively, using a theoretical model. Factors were synthesized based on strength of evidence using vote counting (PROSPERO registration: CRD42020193271).

SETTING AND PARTICIPANTS

Adults with dementia of any subtype and severity, in the last year of life, or in receipt of services indicative of nearness to end of life.

MEASUREMENTS

The primary outcome was ED attendance, defined as attending a medical facility that provides 24-hour access to emergency care, with full resuscitation resources.

RESULTS

After de-duplication, 18,204 titles and abstracts were screened, 367 were selected for full-text review and 23 studies were included. There was high-strength evidence that ethnic minority groups, increasing number of comorbidities, neuropsychiatric symptoms, previous hospital transfers, and rural living were positively associated with ED attendance, whereas higher socioeconomic position, being unmarried, and living in a care home were negatively associated with ED attendance. There was moderate-strength evidence that being a woman and receiving palliative care were negatively associated with ED attendance. There was only low-strength evidence for factors associated with repeat ED attendance.

CONCLUSIONS AND IMPLICATIONS

The review highlights characteristics that could help identify patients at risk of ED attendance near the end of life and potential service-related factors to reduce risks. Better understanding of the mechanisms by which residential facilities and palliative care are associated with reduced ED attendance is needed.

Influenza outbreaks in aged care facilities in New South Wales in 2017: impact and lessons for surveillance

Introduction

A record number of influenza outbreaks in aged care facilities (ACFs) in New South Wales (NSW) during 2017 provided an opportunity to measure the health impact of those outbreaks and assess the quality of routinely available surveillance data.

Methods

Data for all ACF influenza outbreaks in NSW in 2017 were extracted from the Notifiable Conditions Information Management System. The numbers of outbreaks, residents with influenza-like illness (ILI), hospital admissions and deaths were assessed. For each outbreak the attack rate; duration; timeliness of notification; resident and staff influenza vaccination coverage; and antiviral use for treatment or prophylaxis were analysed. Data were considered for NSW in total and separately for seven of the state's local health districts. Data completeness was assessed for all available variables.

Results

A total of 538 ACF outbreaks resulted in 7,613 residents with ILI, 793 hospitalisations and 338 deaths. NSW outbreaks had a median attack rate of 17% and median duration of eight days. Data completeness, which varied considerably between districts, limited the capacity to accurately consider some important epidemiological and policy issues.

Discussion

Influenza outbreaks impose a major burden on the residents and staff of ACFs. Accurate assessment of the year-to-year incidence and severity of influenza outbreaks in these facilities is important for monitoring the effectiveness of outbreak prevention and management strategies. Some key data were incomplete and strategies to improve the quality of these data are needed, particularly for: the number of influenza-related deaths among residents; resident and staff vaccination coverage prior to outbreaks; and recorded use of antiviral prophylaxis.

Decision difficulties of long-term-care facility nurses in transferring residents to the emergency department: A cross-sectional nationwide study

AIMS

To examine the level of decision difficulties of long-term-care facility (LTCF) nurses when transferring residents to the emergency department (ED) and associated influencing factors.

DESIGN

A cross-sectional nationwide study.

METHODS

The LTCFs were selected through random stratified sampling across the whole Taiwan during February 2018 to January 2019. LTCF nurses who met the selection criteria were invited to participate with two or three nurses selected from each LTCF. The Patient Transfer Decision Difficulty Scale (PTDDS) was used to measure the level of difficulty in making decisions related to the transfer of residents to the ED. Data were collected by mailing the questionnaires and asking the nurses to return the completed form in 2 weeks. Data were analysed using simple linear regression and multiple regression with stepwise methods.

RESULTS

In total, 618 valid questionnaires with an 85.32% response rate from 319 LTCFs were used for the data analysis. Decision difficulties that LTCF nurses experienced were moderate, the nursing personnel-bed ratio, LTCF professional training and basic life support training were predictive factors of the level of difficulty experience (scores of PTDDS) for the LTCF nurse (F = 6.81, p < .001).

CONCLUSIONS

Enhancing emergency training in LTCF can improve nurses' decision-making ability to refer LTCF residents to emergency treatment.

IMPACT

What problem did the study address? The study addressed the difficult decision LTCF nurses may experience when transferring a resident to the emergency department. What were the main findings? All LTCF nurses faced a moderate level of difficulty in decision-making. 'Transfer timing' was most often considered in the decision-making process when a resident was transferred to the ED. Where and on whom will the research have impact? Results of this study have considerable reference value for LTCF managers and nurses in the decision-making ability and suitability of transferring residents for emergency treatment.

Surgical Outcomes among Focused versus Diversified Cataract Surgeons

PURPOSE

Narrowly focused surgical practice has become increasingly common in ophthalmology and may have an effect on surgical outcomes. Previous research evaluating the influence of surgical focus on cataract surgical outcomes has been lacking. This study aimed to evaluate whether surgeons' exclusive surgical focus on cataract surgery influences the risk of cataract surgical adverse events.

DESIGN

Population-based cohort study.

PARTICIPANTS

All patients 66 years of age or older undergoing cataract surgery in Ontario, Canada, between January 1, 2002, and December 31, 2013.

METHODS

Outcomes of isolated cataract surgery performed by exclusive cataract surgeons (no other types of surgery performed), moderately diversified cataract surgeons (1%-50% noncataract procedures), and highly diversified cataract surgeons (>50% noncataract procedures) were evaluated using linked healthcare databases and controlling for patient-, surgeon-, and institution-level covariates. Surgeon-level covariates included both surgeon experience and surgical volume.

MAIN OUTCOME MEASURES

Composite outcome incorporating 4 adverse events: posterior capsule rupture, dropped lens fragments, retinal detachment, and suspected endophthalmitis.

RESULTS

The study included 1 101 864 cataract operations. Patients had a median age of 76 years, and 60.2% were female. Patients treated by the 3 groups of surgeons were similar at baseline. Adverse events occurred in 0.73%, 0.78%, and 2.31% of cases performed by exclusive cataract surgeons, moderately diversified surgeons, and highly diversified surgeons, respectively. The risk of cataract surgical adverse events for patients operated on by moderately diversified surgeons was not different than for patients operated on by exclusive cataract surgeons (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.00-1.18). Patients operated on by highly diversified surgeons had a higher risk of adverse events than patients operated on by exclusive cataract surgeons (OR, 1.52; 95% CI, 1.09-2.14). This resulted in an absolute risk difference of 0.016 (95% CI, 0.012-0.020) and a number needed to harm of 64 (95% CI, 50-87).

CONCLUSIONS

Exclusive surgical focus did not affect the safety of cataract surgery when compared with moderate levels of surgical diversification. The risk of cataract surgical adverse events was higher among surgeons whose practice was dedicated mainly to noncataract surgery.

Health service utilisation and health outcomes of residential aged care residents referred to a hospital avoidance program: A multi-site retrospective quasi-experimental study

OBJECTIVE

To compare the health system utilisation patterns and health outcomes of residential aged care facility (RACF) residents reviewed by a hospital avoidance program to those of RACF residents who received usual care.

METHODS

A retrospective evaluation of a hospital avoidance program provided by a hospital-based medical and nursing outreach team. Residents reviewed by the program were randomly matched 1:1 to comparison group residents based on age group, sex and number of co-morbidities. Number of hospital admissions, excess hospital length of stay and excess hospital treatment costs were compared.

RESULTS

Residents reviewed by the program spent an average 9-10 days fewer in hospital with AUD$2,091 to $8,014 lower hospital treatment costs compared to comparison group residents.

CONCLUSION

Rapid provision of outreach services for the management of acute care of RACF residents may reduce the number of days residents spend in hospital, as well as reducing the associated hospital treatment costs.

Development of the PriCARE classification for potentially preventable emergency department visits by ambulance: a RAND/UCLA modified Delphi study protocol

INTRODUCTION

Ontario ambulances are restricted from patient transportation to sub-acute levels of care when these facilities may be more suitable than emergency departments for non-emergent conditions. There is no known patient classification specifically constructed to inform ED diversion protocols and guidance for sub-acute centre transportation for primary care-like patient conditions.

OBJECTIVE

To construct a novel patient classification of potentially preventable emergency department visits following transport by ambulance, and analyse patient-level characteristic associations with this classification based in Ontario secondary data.

METHODS AND ANALYSIS

The Primary Care-like Ambulance transports following Response for 911-Emergencies (PriCARE) patient classification will be constructed using a two-phase RAND/UCLA modified Delphi design. All experts included are physicians with relevant experience in emergency and/or primary care in Ontario. The first phase of the study will determine consensus of the expert committee on which ED interventions performed on patients with non-emergent acuities could be conducted in sub-acute healthcare centres. The second phase will assess consensus of which patient, hospital and acuity factors are most appropriate to be incorporated into a PriCARE classification. We will also investigate secondary outcomes on consensus of which ED interventions could be transferred to a paramedic context given an expanded scope of practice and patient-level characteristics of PriCARE classified individuals.

ETHICS AND DISSEMINATION

This study received a research ethics board exemption waiver from the Hamilton Integrated Research Ethics Board; review reference 2020-11451-GRA. Results will be submitted for publication in a peer-reviewed journal and presented at relevant conferences. The results will be shared with Ontario paramedic services and governing institutions. This study will be used to inform patient classification protocols and clinical decision tools for ambulances to transport to sub-acute healthcare centres.

TRIAL REGISTRATION NUMBER

ISRCTN22901977.

Rural-Urban Differences in Nursing Home Risk-adjusted Rates of Emergency Department Visits: A Decomposition Analysis

BACKGROUND

Higher risk-adjusted rate of emergency department (ED) visits might reflect poor quality of nursing home (NH) care; however, existing evidence is limited regarding rural-urban differences in ED rates of NHs, especially for long-stay residents.

OBJECTIVES

To determine and quantify sources of rural-urban differences in NH risk-adjusted rates of any ED visit, ED without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED) of long-stay residents.

RESEARCH DESIGN

We calculated quarterly NH risk-adjusted rates using 2011-2013 national Medicare claims and Minimum Data Set 3.0, and then implemented Generalized Estimating Equation models to examine rural-urban differences in ED rates and Blinder-Oaxaca decomposition to quantify the contributions of NH and market factors.

SUBJECTS

Privately owned, free-standing NHs in the United States (N=13,260).

RESULTS

Over the study period, risk-adjusted rates averaged 9.8% for any ED, 3.3% for outpatient ED, and 3.2% for PAED. Compared with urban NHs, rural NHs were associated with significantly lower rates of any ED, outpatient ED, and PAED (β=-1.67%, -0.44%, and -0.28%; all P<0.01). Observable differences in market factors (nursing home bed concentration, hospital beds, and the existence of a critical access hospital) explained about half of the rural-urban differences in rates of any ED and PAED, but not outpatient ED.

CONCLUSIONS

Decomposition analyses suggested that lower ED rates in rural NHs appear to be related to market availability of hospital resources. Policymakers may focus on not only reducing unnecessary ED visits but also ensuring equitable hospital access in rural areas.

Predictors of Initial Glaucoma Therapy with Laser Trabeculoplasty versus Medication: A Population-Based Study

PURPOSE

To investigate patient-level factors associated with first-line glaucoma therapy with laser trabeculoplasty (LT) versus topical medication.

DESIGN

Population-based study.

PARTICIPANTS

All patients 66 years of age and older in Ontario, Canada, receiving first-ever therapy for glaucoma with either LT or topical medication between April 1, 2007, and March 31, 2019.

METHODS

Linked health care databases were used to identify patients receiving first-line glaucoma therapy and to ascertain patient-level factors potentially associated with receipt of LT versus medication. Multivariate logistic regression analyses were undertaken.

MAIN OUTCOME MEASURES

Factors associated with receiving LT versus medications were evaluated using adjusted odds ratios (ORs) for age, gender, previous cataract surgery, previous corneal transplantation, previous retina surgery, level of systemic comorbidity, socioeconomic status (SES), and rural versus urban residence.

RESULTS

In total, 194 759 patients were included. Older patients were less likely to be treated with LT versus medication (≥81 years of age vs. 66-70 years of age: OR, 0.49; 95% confidence interval [CI], 0.48-0.50), whereas women were more likely than men to receive LT (OR, 1.42; 95% CI, 1.39-1.45). Previous ocular surgeries were associated with decreased probability of treatment with LT, including cataract surgery (OR, 0.31; 95% CI, 0.30-0.32), corneal transplantation (OR, 0.39; 95% CI, 0.31-0.49), and retina surgery (OR, 0.46; 95% CI, 0.41-0.51). Patients with high comorbidity were less likely to receive LT (highest vs. lowest level of comorbidity: OR, 0.94; 95% CI, 0.91-0.97). Laser trabeculoplasty use was less likely among patients at higher levels of SES (highest vs. lowest level: OR, 0.86; 95% CI, 0.84-0.89) and from a rural residence (versus urban: OR, 0.92; 95% CI, 0.90-0.95). Increasing utilization of LT over time was noted (for each additional calendar year: OR, 1.05 per year; 95% CI, 1.05-1.05 per year).

CONCLUSIONS

Our results identified patient characteristics associated with use of LT as primary therapy for glaucoma, including factors related to patient demographics, ocular history, and comorbidity. Many of these associations are unexpected based on efficacy data or evidence-based guidelines. These results are topical considering growing evidence supporting use of first-line LT.

Diagnostic Testing in Long-Term Care and Resident Emergency Department Visits: A Retrospective Cohort Study

OBJECTIVES

To investigate the association between rapid access to radiographs, blood tests, urine cultures, and intravenous (IV) therapy in a long-term care (LTC) home with resident transfers to the emergency department (ED).

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

21,811 residents living in 162 LTC homes in Ontario, Canada.

METHODS

We administered a survey to LTC homes to collect wait times for radiographs, basic blood tests, urine culture, and IV therapy. Rapid availability was defined as typically receiving test results within 1 or 2 days, or same-day IV therapy. We linked the survey results to administrative data and defined a cohort of residents living in survey-respondent homes between January and May 2017. We followed residents in the linked administrative databases for 6 months, until discharge, or death. Two physicians identified diagnostic codes for ED visits that were potentially preventable with rapid availability of each of the 4 resources. Multilevel logistic regression models estimated associations between potentially preventable ED visits and rapid diagnostic tests and intravenous access while controlling for demographic characteristics, illness severity, LTC home size, chain status, and physician availability.

RESULTS

Rapid blood tests, radiographs, urine culture, and IV therapy were available in 55%, 47%, 34%, and 45% of LTC homes, respectively. LTC homes that were part of multihome chains were less likely to have rapid access to the 4 resources. Of the 4736 residents (27%) who visited an ED during follow-up, individuals from homes with rapid access to radiographs (odds ratio 0.79, 95% confidence interval 0.66-0.97), urine culture (0.88, 0.72-1.08), blood tests (0.83, 0.69-1.00), and IV therapy (0.93, 0.70-1.23) tended to have fewer potentially preventable ED visits.

CONCLUSIONS AND IMPLICATIONS

Rapid access to diagnostic testing and IV therapy in LTC reduced ED visits. Improving access to these resources may prevent ED visits and allow residents to stay home.

Nursing Home Residents Face Severe Functional Limitation or Death After Hospitalization for Pneumonia

Objectives

Pneumonia is a common cause of hospitalization for nursing home residents and has increased as a cause for hospitalization during the COVID-19 pandemic. Risks of hospitalization, including significant functional decline, are important considerations when deciding whether to treat a resident in the nursing home or transfer to a hospital. Little is known about postdischarge functional status, relative to baseline, of nursing home residents hospitalized for pneumonia. We sought to determine the risk of severe functional limitation or death for nursing home residents following hospitalization for treatment of pneumonia.

Design

Retrospective cohort study.

Setting and Participants

Participants included Medicare enrollees aged ≥65 years, hospitalized from a nursing home in the United States between 2013 and 2014 for pneumonia.

Methods

Activities of daily living (ADL), patient sociodemographics, and comorbidities were obtained from the Minimum Data Set (MDS), an assessment tool completed for all nursing home residents. MDS assessments from prior to and following hospitalization were compared to assess for functional decline. Following hospital discharge, all patients were evaluated for a composite outcome of severe disability (≥4 ADL limitations) following hospitalization or death prior to completion of a postdischarge MDS.

Results

In 2013 and 2014, a total of 241,804 nursing home residents were hospitalized for pneumonia, of whom 89.9% (192,736) experienced the composite outcome of severe disability or death following hospitalization for pneumonia. Although we found that prehospitalization functional and cognitive status were associated with developing the composite outcome, 53% of residents with no prehospitalization ADL limitation, and 82% with no cognitive limitation experienced the outcome.

Conclusions and Implications

Hospitalization for treatment of pneumonia is associated with significant risk of functional decline and death among nursing home residents, even those with minimal deficits prior to hospitalization. Nursing homes need to prepare for these outcomes in both advance care planning and in rehabilitation efforts.

Improving care for residents in long term care facilities experiencing an acute change in health status

Background

Long term care (LTC) facilities provide health services and assist residents with daily care. At times residents may require transfer to emergency departments (ED), depending on the severity of their change in health status, their goals of care, and the ability of the facility to care for medically unstable residents. However, many transfers from LTC to ED are unnecessary, and expose residents to discontinuity in care and iatrogenic harms. This knowledge translation project aims to implement a standardized LTC-ED care and referral pathway for LTC facilities seeking transfer to ED, which optimizes the use of resources both within the LTC facility and surrounding community.

Methods/design

We will use a quasi-experimental randomized stepped-wedge design in the implementation and evaluation of the pathway within the Calgary zone of Alberta Health Services (AHS), Canada. Specifically, the intervention will be implemented in 38 LTC facilities. The intervention will involve a standardized LTC-ED care and referral pathway, along with targeted INTERACT® tools. The implementation strategies will be adapted to the local context of each facility and to address potential implementation barriers identified through a staff completed barriers assessment tool. The evaluation will use a mixed-methods approach. The primary outcome will be any change in the rate of transfers to ED from LTC facilities adjusted by resident-days. Secondary outcomes will include a post-implementation qualitative assessment of the pathway. Comparative cost-analysis will be undertaken from the perspective of publicly funded health care.

Discussion

This study will integrate current resources in the LTC-ED pathway in a manner that will better coordinate and optimize the care for LTC residents experiencing an acute change in health status.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05919-7.

Reducing Emergency Department Transfers from Skilled Nursing Facilities Through an Emergency Physician Telemedicine Service

Introduction

Transfers of skilled nursing facility (SNF) residents to emergency departments (ED) are linked to morbidity, mortality and significant cost, especially when transfers result in hospital admissions. This study investigated an alternative approach for emergency care delivery comprised of SNF-based telemedicine services provided by emergency physicians (EP). We compared this on-site emergency care option to traditional ED-based care, evaluating hospital admission rates following care by an EP.

Methods

We conducted a retrospective, observational study of SNF residents who underwent emergency evaluation between January 1, 2017–January 1, 2018. The intervention group was comprised of residents at six urban SNFs in the Northeastern United States, who received an on-demand telemedicine service provided by an EP. The comparison group consisted of residents of SNFs that did not offer on-demand services and were transferred via ambulance to the ED. Using electronic health record data from both the telemedicine and ambulance transfers, our primary outcome was the odds ratio (OR) of a hospital admission. We also conducted a subanalysis examining the same OR for the three most common chronic disease-related presentations found among the telemedicine study population.

Results

A total of 4,606 patients were evaluated in both the SNF-based intervention and ED-based comparison groups (n=2,311 for SNF based group and 2,295 controls). Patients who received the SNF-based acute care were less likely to be admitted to the hospital compared to patients who were transferred to the ED in our primary and subgroup analyses. Overall, only 27% of the intervention group was transported to the ED for additional care and presumed admission, whereas 71% of the comparison group was admitted (OR for admission = 0.15 [9% confidence interval, 0.13–0.17]).

Conclusion

The use of an EP-staffed telemedicine service provided to SNF residents was associated with a significantly lower rate of hospital admissions compared to the usual ED-based care for a similarly aged population of SNF residents. Providing SNF-based care by EPs could decrease costs associated with hospital-based care and risks associated with hospitalization, including cognitive and functional decline, nosocomial infections, and falls.

Root cause analysis of fall-related hospitalisations among residents of aged care services

BACKGROUND

Fall-related hospitalisations from residential aged care services (RACS) are distressing for residents and costly to the healthcare system. Strategies to limit hospitalisations include preventing injurious falls and avoiding hospital transfers when falls occur.

AIMS

To undertake a root cause analysis (RCA) of fall-related hospitalisations from RACS and identify opportunities for fall prevention and hospital avoidance.

METHODS

An aggregated RCA of 47 consecutive fall-related hospitalisations for 40 residents over a 12-month period at six South Australian RACS was undertaken. Comprehensive data were extracted from RACS records including nursing progress notes, medical records, medication charts, hospital summaries and incident reports by a nurse clinical auditor and clinical pharmacist. Root cause identification was performed by the research team. A multidisciplinary expert panel recommended strategies for falls prevention and hospital avoidance.

RESULTS

Overall, 55.3% of fall-related hospitalisations were among residents with a history of falls. Among all fall-related hospitalisations, at least one high falls risk medication was administered regularly prior to hospitalisation. Potential root causes of falling included medication initiations and dose changes. Root causes for hospital transfers included need for timely access to subsidised medical services or radiology. Strategies identified for avoiding hospitalisations included pharmacy-generated alerts when medications associated with an increased risk of falls are initiated or changed, multidisciplinary audit and feedback of falls risk medication use and access to subsidised mobile imaging services.

CONCLUSIONS

This aggregate RCA identified a range of strategies to address resident and system-level factors to minimise fall-related hospitalisations.

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

OBJECTIVE

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

DESIGN

Quality improvement study with randomized assignment.

SETTINGS AND PARTICIPANTS

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

METHODS

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

RESULTS

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

CONCLUSIONS AND IMPLICATIONS

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

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

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