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

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.

End user information needs for a SMART on FHIR-based automated transfer form to support the care of nursing home patients during emergency department visits

Nursing home (NH) patients are extensive users of emergency department (ED) services. Problematically, poor information sharing and incomplete access to information complicates the delivery of care in EDs for NH patients. Paper-based transfer forms can support information sharing, but have significant limitations. Standards-based automated transfer-forms that leverage health information exchange data may address the limitations of paper-based forms and better support care delivery. This study developed a prototype SMART on FHIR automated transfer form for NH patients using priority data elements identified through individual interviews, a review of existing transfer forms, a targeted survey of end users, and a design workshop. Analyses were grounded in the 5 Rights of clinical decision support framework. The most valuable data elements included: emergency contact/healthcare proxy, current medication list, reason for transfer to the ED, baseline neurological state, and relevant diagnoses / medical history. The working prototype was successfully deployed within an Amazon Web Service environment.

An Assessment of Handover Culture and Preferred Information in the Transitions of Care of Elderly Patients

Introduction Transitions of care for elderly patients in long term care (LTC) to the emergency department (ED) is fraught with communication challenges. Information preferred during these transitions has not been agreed upon. We sought to understand our local handover culture and identify what information is preferred in the transitions of care of these patients. Methods We performed a cross-sectional electronic survey that was distributed to 1470 healthcare providers (HCPs) and 82 patient and family advocates (PFAs) in two Canadian cities. The HCP group consisted of physicians and nurses in ED and LTC settings as well as paramedics. The survey was open for a period of one month with formal reminders sent weekly. Results A total of 12.9% of HCPs and 26.8% of PFAs responded to the survey. Only 41.3% of HCP respondents were aware of existing handover protocols and 83.2% indicated a desire for a single page handover form. HCPs identified concerns over handover culture surrounding workplace inefficiencies and increased demands to their time. Several preferred items of information in the transitions of care for the institutionalized elderly patient were also identified across both HCP and PFA groups. Conclusions Our study identified a need for improved local handover culture in transitions of care for the institutionalized elderly patient. We also identified the preferred elements of information during bilateral communication between LTC and the ED. Our results will be used to design a patient-centred handover form for future use in this population.